USCDI Export for the Public

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Classification Level Data Class Data Class Description Data Element Data Element Description Applicable Standards Submitter Name Submitter Organization Submission Date
USCDI V1 Patient Demographics/Information

Data used to categorize individuals for identification, records matching, and other purposes.

 Phone Number Type
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 Patient Demographics/Information

Data used to categorize individuals for identification, records matching, and other purposes.

 Previous Address

Includes street name, number, city/town, state, and zip code.
USCDI V1 Allergies and Intolerances

Harmful or undesired physiological responses associated with exposure to a substance.

 Reaction
  • SNOMED International, Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT®) U.S. Edition, September 2019 Release
USCDI V1 Allergies and Intolerances

Harmful or undesired physiological responses associated with exposure to a substance.

 Substance (Drug Class)
  • SNOMED International, Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT®) U.S. Edition, September 2019 Release
USCDI V1 Clinical Notes

Narrative patient data relevant to the context identified by note types.

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  • 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. 
 Progress Note

Represents a patient’s interval status during a hospitalization, outpatient visit, treatment with a post-acute care provider, or other healthcare encounter.

Logical Observation Identifiers Names and Codes (LOINC®) version 2.67

  • Progress Note (LOINC® code 11506-3)
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 Allergies and Intolerances

Harmful or undesired physiological responses associated with exposure to a substance.

 Substance (Medication)
  • RxNorm®, January 6, 2020 Full Release Update
USCDI V1 Vital Signs

Physiologic measurements of a patient that indicate the status of the body’s life sustaining functions.

 Head Occipital-frontal Circumference Percentile (Birth - 36 Months)
  • 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.

 Current Address

Includes street name, number, city/town, state, and zip code.
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.

 Weight-for-length Percentile (Birth - 36 Months)
  • 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.

 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 Patient Demographics/Information

Data used to categorize individuals for identification, records matching, and other purposes.

 Phone Number

Both standards are required

  • ITU-T E.123, Series E: Overall Network Operation, Telephone Service, Service Operation and Human Factors, International operation - General provisions concerning users: Notation for national and international telephone numbers, email addresses and web addresses, February 2001
  • ITU-T E.164, Series E: Overall Network Operation, Telephone Service, Service Operation and Human Factors, International operation - Numbering plan of the international telephone service, The international public telecommunication numbering plan, November 2010

Adopted at 45 CFR 170.207(q)(1)
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 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 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 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 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. 
 Discharge Summary Note

A synopsis of a patient’s admission and course in a hospital or post-acute care setting.

Logical Observation Identifiers Names and Codes (LOINC®) version 2.67

  • Discharge Summary (LOINC® code 18842-5)
USCDI V1 Unique Device Identifier(s) for a Patient's Implantable Device(s)

Unique identifier(s) for a patient's implantable device(s).

 Unique Device Identifier(s) for a patient's implantable device(s) Marti Velezis FDA/CDRH/Indira Konduri (FDA/CDRH/OPEQ/ORP/DRPIII)