USCDI Export for the Public
| Classification Level Sort descending | Data Class | Data Class Description | Data Element | Data Element Description | Applicable Standards | Submitter Name | Submitter Organization | Submission Date |
|---|---|---|---|---|---|---|---|---|
| USCDI V2 | Vital Signs | Physiologic measurements of a patient that indicate the status of the body’s life sustaining functions. |
Body Temperature |
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| USCDI V2 | Problems | Condition, diagnosis, or reason for seeking medical attention. |
Problems |
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| USCDI V2 | Patient Demographics/Information | Data used to categorize individuals for identification, records matching, and other purposes. |
Previous Name | |||||
| Level 2 | Patient Demographics/Information | Data used to categorize individuals for identification, records matching, and other purposes. |
Patient Identifier Type | Identifies the type of identifier payers and providers assign to patients |
NUBC, CPT, HCPCS, HIPPS, ICD-9, ICD-10, DRGs, NDC, POS, NCPDP codes, and X12 codes. |
Mark Roberts | Leavitt Partners | |
| Level 2 | Organization | Healthcare Services | Describe a specific healthcare service or category of services (such as counseling, imaging, or laboratory) offered by an organization at a designated location, which can be either physical or virtual. The service provider may include hospitals, clinics, pharmacies, or other specialized healthcare providers. |
In addition to LOINC and SNOMED CT, other relevant code systems for the Healthcare Service data element include: 1. NDC (National Drug Code): For identifying medications and drug services. These additional code systems further support the standardized representation of healthcare services. |
Mike Hamidi | Vulcan | ||
| Level 2 | Patient Demographics/Information | Data used to categorize individuals for identification, records matching, and other purposes. |
Deceased Indicator | Indicates if the individual is deceased or not. |
Sarah Gaunt | The Association of Public Health Laboratories (APHL) | ||
| Level 2 | Orders | Provider-authored request for the delivery of patient care services. |
Nutrition Order | A clinician (provider)-authored request for a diet, formula feeding (enteral), or nutritional supplement. |
SNOMED CT |
Michelle Ashafa | Academy of Nutrition and Dietetics | |
| Level 2 | Orders | Provider-authored request for the delivery of patient care services. |
Referral Orders | Provider-authored request to another provider, specialist, or organization for care services. Examples include referral orders to a wound specialist or podiatrist. |
SNOMED CT |
Grace Glennon, on behalf of NCQA | NCQA | |
| Level 2 | Patient Summary and Plan | Conclusions and working assumptions that will guide treatment of the patient, and recommendations for future treatment. |
Care Plan |
Shared plan informed by members of a coordinated care team that details conditions, needs, and goals along with strategies for addressing them. Usage notes: Includes prioritized problems, health concerns, assessments, goals, and interventions from across care settings. Examples include nursing care plan, diabetic care plan, multiple chronic conditions care plan, and long term services and support care plan. |
LOINC, HL7 C-CDA and FHIR |
Julia Skapik | NACHC | |
| Level 2 | Medical Devices | An instrument, machine, appliance, implant, software or other article intended to be used for a medical purpose. |
Medical Device Status | Information beyond the UDI is required for patient care and clinical research. If a patient record is transferred to a new provider, the implant date of all active and inactive devices as well as the explant date of previously implantable devices is relevant. To conduct safety and effectiveness research, implant date, explant date and therapy status are relevant. Proposing implanted/inactivated/reactivated/explanted as the status values and that the status history is included as opposed to only current status. | NCI Thesaurus |
TICIA Louise GERBER | Health Level Seven International | |
| Level 2 | Health Insurance Information | Data related to an individual’s insurance coverage for health care. |
Plan Identifier | Business concept used by a health plan to describe its benefit offerings. |
NUBC, CPT, HCPCS, HIPPS, ICD-9, ICD-10, DRGs, NDC, POS, NCPDP codes, and X12 codes. |
Mark Roberts | Leavitt Partners | |
| Level 2 | Diagnostic Imaging | Tests that result in visual images requiring interpretation by a credentialed professional. |
Accession Number | A unique identifier created by a departmental information system which identifies the Imaging Service Request. The Accession Number links the scheduled procedure, images, and their resulting diagnostic imaging report, created by the radiologist, back to the original order, supporting both clinical workflow and billing. The Accession Number may group one or more Requested Procedures. |
LOINC/RSNA Radiology Playbook includes Diagnostic Imaging Procedure Codes and Descriptions. |
Brian Bialecki | American College of Radiology | |
| Level 2 | Medical Devices | An instrument, machine, appliance, implant, software or other article intended to be used for a medical purpose. |
Device used | Devices are an identifiable grouping of mobility devices (i.e., wheelchairs), implantable devices (i.e., pace makers), or other wearable devices (i.e. compression socks or venous foot pump) with significant impact on patient functionality and health. The QDM v5.5 notes that “Device represents an instrument, apparatus, implement, machine, contrivance, implant, in-vitro reagent, or other similar or related article, including a component part or accessory, intended for use in the diagnosis, cure, mitigation, treatment, or prevention of disease and not dependent on being metabolized to achieve any of its primary intended purposes.” |
SNOMED CT (Frailty Device, value set OID: 2.16.840.1.113883.3.464.1003.118.12.1300) SNOMED CT (Intermittent Pneumatic Compression Devices (IPC), value set OID: 2.16.840.1.113883.3.117.1.7.1.214) SNOMED CT (Graduated Compression Stockings (GSC), value set OID: 2.16.840.1.113883.3.117.1.7.1.256) SNOMED CT (Venous Foot Pumps (VFP), value set OID: 2.16.840.1.113883.3.117.1.7.1.230) SNOMED CT (Cardiac Pacer, value set OID: 2.16.840.1.113883.3.526.3.1193) ICD-10-CM, SNOMED CT (Cardiac Pacer in Situ, value set OID: 2.16.840.1.113883.3.526.3.368) |
Joel Andress | Centers for Medicare and Medicaid Services (CMS) Center for Clinical Standards and Quality (CCSQ) | |
| Level 2 | Allergies and Intolerances | Harmful or undesired physiological responses associated with exposure to a substance. |
Criticality | Estimate of the potential clinical harm, or seriousness, of a reaction to an identified substance. |
HL7 FHIR R4 Allergy Intolerance Criticality, Rx Norm, SNOMED CT, National Drug Code (NDC) |
Sandi Mitchell | J P Systems, Inc. | |
| Level 2 | Health Insurance Information | Data related to an individual’s insurance coverage for health care. |
Group Name | Name of the Employer Account. |
NUBC, CPT, HCPCS, HIPPS, ICD-9, ICD-10, DRGs, NDC, POS, NCPDP codes, and X12 codes. |
Mark Roberts | Leavitt Partners | |
| Level 2 | Diagnostic Imaging | Tests that result in visual images requiring interpretation by a credentialed professional. |
Imaging Reference | The technical details of the retrieval access path to indicate network services that can be used to access DICOM studies, series, or instances content and metadata (e.g., a DICOMweb server endpoint providing QIDO-RS, WADO-RS, or WADO-URI). |
LOINC/RSNA Radiology Playbook includes Diagnostic Imaging Procedure Codes and Descriptions. HL7 Standard for CDA® Release 2: Imaging Integration; Basic Imaging Reports in CDA and DICOM Release 1 references LOINC® Document Type Codes, SNOMED CT® Quantity Measurement Type Codes, as well as DICOM Code Systems. FHIR ImagingStudy references SNOMED CT Body Structures |
Brian Bialecki | American College of Radiology | |
| Level 2 | Nutrition and Diet | Enteral Nutrition Type | Enteral Nutrition is the delivery of nutrients to a functional segment of the gastrointestinal tract distal to the oral cavity employing the use of a tube or catheter device to supply a liquid formula. This data element is for the type or brand name of the enteral formula. |
HL7 Version 2 – ODS – Dietary orders, supplements, and preferences (http://www.hl7.org/implement/standards/product_brief.cfm?product_id=185) In addition, many there are many nutrition-related terms in SNOMED CT. Many of these terms have been put in value sets in VSAC or through HL7 terminology. Here are some examples: |
Becky Gradl | Academy of Nutrition and Dietetics | ||
| Level 2 | Orders | Provider-authored request for the delivery of patient care services. |
Portable Medical Orders | Orders for certain aspects of medical care, including end-of-life care, which support a transfer of care request from one practitioner or organization to another that provides end-of-life or life-sustaining care services. Different types of portable medical orders are used in different jurisdictions. |
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Grace Glennon on behalf of Joel Andress and CMS-CCSQ | On behalf of Centers for Medicare and Medicaid Services (CMS) Center for Clinical Standards and Quality (CCSQ) | |
| Level 2 | Nutrition and Diet | Oral Diet Type | The name or type of oral diet or diet restrictions that describe what can be consumed orally. For example “general healthful diet”, “consistent carbohydrate diet”, or “renal diet”. |
HL7 Version 2 – ODS – Dietary orders, supplements, and preferences (http://www.hl7.org/implement/standards/product_brief.cfm?product_id=185) In addition, many there are many nutrition-related terms in SNOMED CT. Many of these terms have been put in value sets in VSAC or through HL7 terminology. Here are some examples: |
Becky Gradl | Academy of Nutrition and Dietetics | ||
| Level 2 | Orders | Provider-authored request for the delivery of patient care services. |
Medical Device Orders | Provider-authored request for medical devices, such as for therapeutic footwear or walking aids. |
SNOMED CT |
Grace Glennon, on behalf of NCQA | NCQA |