USCDI Export for the Public

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Classification Level Sort descending	Data Class	Data Class Description	Data Element	Data Element Description	Applicable Standards
USCDI V1	Clinical Notes	Narrative patient data relevant to the context identified by note types. Usage note: Clinical Notes data elements are content exchange standard agnostic. They should not be interpreted or associated with the structured document templates that may share the same name.	Procedure Note	Encompasses non-operative procedures including interventional cardiology, gastrointestinal endoscopy, osteopathic manipulation, and other specialty’s procedures.	Logical Observation Identifiers Names and Codes (LOINC®) version 2.67 Procedure Note (LOINC® code 28570-0)
USCDI V1	Vital Signs	Physiologic measurements of a patient that indicate the status of the body’s life sustaining functions.	Respiratory Rate		Logical Observation Identifiers Names and Codes (LOINC®) version 2.67 The Unified Code of Units for Measure (UCUM), Revision 2.1
USCDI V1	Patient Demographics/Information	Data used to categorize individuals for identification, records matching, and other purposes.	Preferred Language		Request for Comment (RFC) 5646, “Tags for Identifying Languages”, September 2009 Adopted at 45 CFR 170.207(g)
USCDI V1	Vital Signs	Physiologic measurements of a patient that indicate the status of the body’s life sustaining functions.	Heart Rate		Logical Observation Identifiers Names and Codes (LOINC®) version 2.67 The Unified Code of Units for Measure (UCUM), Revision 2.1
USCDI V1	Laboratory	Analysis of clinical specimens to obtain information about the health of a patient.	Values/Results	Documented findings of the analysis of a tested specimen. Includes both structured and unstructured (narrative) components.
USCDI V1	Immunizations	Record of vaccine administration.	Immunizations		CDC IIS: Current HL7 Standard Code Set, CVX -- Vaccines Administered, updates through January 31, 2020 CDC National Drug Code (NDC) Directory – Vaccine NDC Linker Table, updates through January 31, 2020
USCDI V1	Smoking Status	Representing a patient’s smoking behavior.	Smoking Status	Representing a patient’s smoking behaviors.	SNOMED International, Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT®) U.S. Edition, September 2019 Release
USCDI V1	Patient Demographics/Information	Data used to categorize individuals for identification, records matching, and other purposes.	Ethnicity		Both standards are required The Office of Management and Budget Standards for Maintaining, Collecting, and Presenting Federal Data on Race and Ethnicity, Statistical Policy Directive No. 15, as revised, October 30, 1997 CDC Race and Ethnicity Code Set Version 1.0 (March 2000) Adopted at 45 CFR 170.207(f)
USCDI V1	Vital Signs	Physiologic measurements of a patient that indicate the status of the body’s life sustaining functions.	Diastolic Blood Pressure		Both standards are required. Logical Observation Identifiers Names and Codes (LOINC®) version 2.67 The Unified Code of Units for Measure (UCUM), Revision 2.1
USCDI V1	Vital Signs	Physiologic measurements of a patient that indicate the status of the body’s life sustaining functions.	Body Temperature		Logical Observation Identifiers Names and Codes (LOINC®) version 2.67 The Unified Code of Units for Measure (UCUM), Revision 2.1
USCDI V1	Assessment and Plan of Treatment	Health professional’s conclusions and working assumptions that will guide treatment of the patient.	Assessment and Plan of Treatment
USCDI V1	Patient Demographics/Information	Data used to categorize individuals for identification, records matching, and other purposes.	Date of Birth
USCDI V1	Patient Demographics/Information	Data used to categorize individuals for identification, records matching, and other purposes.	Birth Sex		Birth sex must be coded in accordance with HL7 Version 3 (V3) Standard, Value Sets for AdministrativeGender and NullFlavor attributed as follows: Female. F Male. M Unknown. nullFlavor UNK Adopted at 45 CFR 170.207(n)
USCDI V1	Clinical Notes	Narrative patient data relevant to the context identified by note types. Usage note: Clinical Notes data elements are content exchange standard agnostic. They should not be interpreted or associated with the structured document templates that may share the same name.	Consultation Note	Contains the response to request from a clinician for an opinion or advice from another clinician.	Logical Observation Identifiers Names and Codes (LOINC®) version 2.67 Consult Note (LOINC® code 11488-4)
USCDI V1	Vital Signs	Physiologic measurements of a patient that indicate the status of the body’s life sustaining functions.	BMI Percentile (2 - 20 years)		Logical Observation Identifiers Names and Codes (LOINC®) version 2.67 The Unified Code of Units for Measure (UCUM), Revision 2.1
USCDI V1	Provenance	The metadata, or extra information about data, regarding who created the data and when it was created.	Author Time Stamp
USCDI V1	Medications	Pharmacologic agents used in the diagnosis, cure, mitigation, treatment, or prevention of disease.	Medications		RxNorm®, January 6, 2020 Full Release Update
USCDI V1	Procedures	Activity performed for or on a patient as part of the provision of care.	Procedures		Healthcare Common Procedure Coding System (HCPCS) Current Procedural Terminology, Fourth Edition (CPT-4) Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT®) U.S. Edition, September 2019 Release Optional: USCDI v1 - International Classification of Diseases ICD-10-PCS 2020 Optional for technology which records dental procedures: Code on Dental Procedures and Nomenclature (CDT), maintained and distributed by the American Dental Association, for dental services.
USCDI V1	Patient Demographics/Information	Data used to categorize individuals for identification, records matching, and other purposes.	Suffix
USCDI V1	Patient Demographics/Information	Data used to categorize individuals for identification, records matching, and other purposes.	Race		Both standards are required The Office of Management and Budget Standards for Maintaining, Collecting, and Presenting Federal Data on Race and Ethnicity, Statistical Policy Directive No. 15, as revised, October 30, 1997 CDC Race and Ethnicity Code Set Version 1.0 (March 2000) Adopted at 45 CFR 170.207(f)