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Classification Level Sort descending	Data Class	Data Class Description	Data Element	Data Element Description	Applicable Standards	Submitter Name	Submitter Organization	Submission Date
Level 2	Patient Demographics/Information	Data used to categorize individuals for identification, records matching, and other purposes.	Identifier	An identifier for the patient	FHIR US Core	Sarah Gaunt	Lantana Consulting Group	10/21/2020 - 02:59
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. 2. ICD (International Classification of Diseases): For coding diagnoses that may relate to specific healthcare services. 3. CPT (Current Procedural Terminology): For coding medical procedures and services provided by healthcare professionals. 4. HCPCS (Healthcare Common Procedure Coding System): For coding healthcare services, supplies, and equipment. These additional code systems further support the standardized representation of healthcare services.	Mike Hamidi	Vulcan	09/30/2024 - 14:42
Level 2	Procedures	Activity performed for or on a patient as part of the provision of care.	Procedure Status	The status of the procedure (e.g., planned, completed).	Procedure Code (same as current USCDIv1): Health Care Financing Administration Common Procedure Coding System (HCPCS), as maintained and distributed by HHS. http://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets/index.html Current Procedural Terminology, Fourth Edition (CPT-4), as maintained and distributed by the American Medical Association, for physician services and other health care services. http://www.ama-assn.org/ama/pub/physician-resources/solutions-managing-your-practice/coding-billing-insurance/cpt.page SNOMED International, Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT®) U.S. Edition, September 2019 Release. http://www.nlm.nih.gov/research/umls/Snomed/snomed_main.html Optional: International Classification of Diseases ICD-10-PCS 2020. http://www.cms.gov/Medicare/Coding/ICD10/index.html Technology which records dental procedures: Code on Dental Procedures and Nomenclature (CDT), maintained and distributed by the American Dental Association, for dental services. http://www.ada.org/en/publications/cdt Procedure Date: HL7 FHIR Datatypes (dateTime\|Period\|string\|Age\|Range) http://hl7.org/fhir/datatypes.html#dateTime http://hl7.org/fhir/datatypes.html#Period http://hl7.org/fhir/datatypes.html#string http://hl7.org/fhir/datatypes.html#Age http://hl7.org/fhir/datatypes.html#Range Procedure Status: HL7 FHIR Event Status (preparation, in-progress, not-done, on-hold, stopped, completed, entered-in-error, unknown). http://hl7.org/fhir/R4/valueset-event-status.html	Maria Michaels	CDC	10/21/2020 - 17:44
Level 2	Facility Information	Physical place of available services or resources.	Facility Contact Information		Various: FHIR DSTU2, 3 and 4, CDA Release 2.0, HL7 V2 PL Data Type	Keith W. Boone	Audacious Inquiry	08/14/2020 - 15:25
Level 2	Health Insurance Information	Data related to an individual’s insurance coverage for health care.	Payer Name	The program or plan underwriter or payor including both insurance and non-insurance agreements, such as patient-pay agreements.	Coverage type and self paid codes; Many of the defined elements in a resource are references to other resources. Using these references, the resources combine to build a web of information about healthcare; ID assigned to the subscriber	Shelly Spiro	Pharmacy HIT Collaborative	10/20/2020 - 20:46
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	09/30/2021 - 22:17
Level 1	Special Alerts for Care Handoffs		Results LOINC	All pending results and contact information for how to obtain	ICD 10, SNOMED, LOINC, RxNorm	Holly Miller, MD	MedAllies	09/22/2022 - 19:51
Level 1	Patient Demographics/Information	Data used to categorize individuals for identification, records matching, and other purposes.	Patient Social Security Number	Records patient’s social security number.	Social Security Administration: https://www.ssa.gov/history/ssn/geocard.html Medicare Beneficiary Identifiers (MBIs): https://www.cms.gov/Medicare/New-Medicare-Card PHIN VADS: Patient Marital Status: https://phinvads.cdc.gov/vads/ViewValueSet.action?id=DB54A32E-D583-4A24-BD9C-234B0C7BD0FD Gender Identity - Gender harmony project definitions: https://www.jointcommission.org/-/media/deprecated-unorganized/imported-assets/tjc/system-folders/topics-library/lgbtfieldguidepdf.pdf?db=web&hash=224B46C31193399359B8113698971F26 FHIR patient extension: birthplace: http://hl7.org/fhir/R4/extension-patient-birthplace.html FHIR patient address.period: http://hl7.org/fhir/us/core/StructureDefinition-us-core-patient.html LOINC pregnancy status: https://loinc.org/82810-3/ Patient Vital Status: PHIN VADS, SNOMED-CT: https://phinvads.cdc.gov/vads/ViewValueSet.action?id=6EA795D5-5C5D-E511-81F8-0017A477041A Patient vital status:CCDA uses Value Set - HealthStatus urn:oid:2.16.840.1.113883.1.11.20.12 Value Set Source: https://vsac.nlm.nih.gov/valueset/2.16.840.1.113883.1.11.20.12/expansion	Maria Michaels	CDC	10/21/2020 - 15:51
Level 1	Health Status Assessments	Assessments of a health-related matter of interest, importance, or worry to a patient, patient’s family, or patient’s healthcare provider that could identify a need, problem, or condition.	PROMIS (Patient-Reported Outcomes Measurement Information System) survey score result	Patient-Reported Outcomes Measurement Information System (PROMIS) program created new paradigms for how clinical research information is collected, used, and reported. PROMIS addressed a need in the clinical research community for a rigorously tested patient reported outcome (PRO) measurement tool that uses recent advances in information technology, psychometrics, and qualitative, cognitive, and health survey research to measure PROs such as pain, fatigue, physical functioning, emotional distress, and social role participation that have a major impact on quality-of-life across a variety of chronic diseases.	ICD-10 : https://www.cms.gov/Medicare/Coding/ICD10 SNOMED CT: https://www.snomed.org/	Kevin Jung	University of California San Francisco Breast Care Center	09/30/2022 - 23:03
Level 1	Health Status Assessments	Assessments of a health-related matter of interest, importance, or worry to a patient, patient’s family, or patient’s healthcare provider that could identify a need, problem, or condition.	Promise Preference (PROPr) Utility Score	PROPr is a score for the PROMIS measurement system. PROPr combines scores from 7 PROMIS domains into a single preference-based score (also called a health utility score). This score captures the preferences of the general adult US population.	ICD-10 : https://www.cms.gov/Medicare/Coding/ICD10 SNOMED CT: https://www.snomed.org/	Kevin Jung	University of California San Francisco Breast Care Center	09/30/2022 - 23:03
Level 1	Health Status Assessments	Assessments of a health-related matter of interest, importance, or worry to a patient, patient’s family, or patient’s healthcare provider that could identify a need, problem, or condition.	Two-item PROMIS®️ global physical and mental health scales	Two-item PROMIS®️ global physical and mental health scales: Global health items provide synoptic information that can be utilized as predictive indictors of health care utilization and mortality.	ICD-10 : https://www.cms.gov/Medicare/Coding/ICD10 SNOMED CT: https://www.snomed.org/	Kevin Jung	University of California San Francisco Breast Care Center	09/30/2022 - 23:03
Level 1	Patient Demographics/Information	Data used to categorize individuals for identification, records matching, and other purposes.	Patient Marital Status	Patient marital status at the time of documentation.	Social Security Administration: https://www.ssa.gov/history/ssn/geocard.html Medicare Beneficiary Identifiers (MBIs): https://www.cms.gov/Medicare/New-Medicare-Card PHIN VADS: Patient Marital Status: https://phinvads.cdc.gov/vads/ViewValueSet.action?id=DB54A32E-D583-4A24-BD9C-234B0C7BD0FD Gender Identity - Gender harmony project definitions: https://www.jointcommission.org/-/media/deprecated-unorganized/imported-assets/tjc/system-folders/topics-library/lgbtfieldguidepdf.pdf?db=web&hash=224B46C31193399359B8113698971F26 FHIR patient extension: birthplace: http://hl7.org/fhir/R4/extension-patient-birthplace.html FHIR patient address.period: http://hl7.org/fhir/us/core/StructureDefinition-us-core-patient.html LOINC pregnancy status: https://loinc.org/82810-3/ Patient Vital Status: PHIN VADS, SNOMED-CT: https://phinvads.cdc.gov/vads/ViewValueSet.action?id=6EA795D5-5C5D-E511-81F8-0017A477041A Patient vital status:CCDA uses Value Set - HealthStatus urn:oid:2.16.840.1.113883.1.11.20.12 Value Set Source: https://vsac.nlm.nih.gov/valueset/2.16.840.1.113883.1.11.20.12/expansion	Maria Michaels	CDC	10/21/2020 - 15:51
Level 1	Facility Information	Physical place of available services or resources.	Facility GPS Coordinates		Various: FHIR DSTU2, 3 and 4, CDA Release 2.0, HL7 V2 PL Data Type	Keith W. Boone	Audacious Inquiry	08/14/2020 - 15:25
Level 1	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.	Maternal Social Determinants of Health Note	The Maternal Social Determinants of Health Note supports the aggregation of significant events, social problems and related health concerns, and plans of care derived from the visits over the course of a maternal care episode. It is a summary of the most critical information maternal care providers capture and share regarding the status of a maternal patient's social issues. The information is aggregated data from which the patient’s interactions with healthcare and social services providers are captured. The Maternal Social Determinants of Health Note includes information such as structured evaluation of risk (e.g., PRAPARE, homelessness, AHC-HRSN screening tool, etc.) for any maternal health SDOH data related to conditions in which people live, learn, work, and play and their effects on health risks and outcomes; plan of care including social support interventions including but not limited to access to care; education; income; food stability; housing; neighborhood characteristics; safety; transportation security; violence/abuse preventions, ETOH, Smoking, Substance use disorder assessment and treatment drug abuse prevention and treatment; living arrangement; Social support involvement baby father involvement; etc.	SNOMED CT 183425000 Social care 61072005 Social factor 315042007 Social support 161152002 Social problem 310134006 Social services 406551008 Social assessment 405076007 Social support status 108329005 Social context finding LOINC 52234-2 Medical social services treatment plan, Assessment information Set 52218-5 Medical social services treatment plan, Referral information Set 29762-2 Social history Narrative 91642-9 Medical Outcomes Study Social Support Survey panel 91663-5 Social support index ICD10 Z60.9 Problem related to social environment, unspecified Z60.8 Other problems related to social environment ICD9 CM Complications of Pregnancy, Childbirth and the Puerperium http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.111.1… ICD10CM, SNOMEDCT Complications of Pregnancy, Childbirth and the Puerperium http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.111.1… Pregnancy https://vsac.nlm.nih.gov/valueset/2.16.840.1.113883.3.526.3.378/expansi…	Andrea Fourquet	IHE USA	04/30/2022 - 01:55
Level 1	Cancer Care		NCI Patient Reported Outcomes (PRO)-Common Terminology for Criteria for Adverse Events (CTCAE)	PRO-CTCAE (NCI Patient Reported Outcomes version of the Common Terminology Criteria for Adverse Events) was developed to evaluate symptomatic toxicities by self-report in adults, adolescents and children participating in cancer clinical trials. It is designed to be utilized in comparison to the Common Terminology Criteria for Adverse Events (CTCAE), the standard lexicon for adverse event reporting in cancer trials.	ICD-10 : https://www.cms.gov/Medicare/Coding/ICD10 SNOMED CT: https://www.snomed.org/	Kevin Jung	University of California San Francisco Breast Care Center	09/30/2022 - 23:03
Level 1	Patient Demographics/Information	Data used to categorize individuals for identification, records matching, and other purposes.	Patient's Primary Care Provider	Patient's nominated care provider. [Knowing this at the patient level can help answer the question at the encounter level whether the pt. was seen by PCP.]	Medicare Beneficiary Identifiers (MBIs)	Nedra Garrett	Centers for Disease Control and Prevention	10/22/2020 - 16:57
Level 1	Patient Demographics/Information	Data used to categorize individuals for identification, records matching, and other purposes.	Variation in Sex Characteristics	Were you born with a variation in your physical sex characteristics? (This is sometimes called being intersex or having a Difference in Sex Development, or DSD.)  No  Yes, my chromosomes, genitals, reproductive organs, or hormone functions were observed to be different from the typical female/male binary at birth and/or I have been diagnosed with an intersex variation or Difference of Sex Development  I don’t know Source: Intersex Data Collection: Your Guide to Question Design. interACT: Advocates for Intersex Youth. 2020. Accessed September 29, 2022. https://interactadvocates.org/intersex-data-collection/	LOINC has an intersex response option, 99502-7, for Recorded sex or gender. LOINC has an intersex response option. We do not endorse the way LOINC conceptualizes intersex (as corresponding to an X response to a sex or gender question).	Sean Cahill	Fenway Health	09/30/2022 - 18:13
Level 1	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.	Airway Management	Patient history and assessments performed by healthcare providers which are used to identify airway management techniques used and potential complications. These elements are important for any patients undergoing airway management, whether in the emergency department, in the intensive care unit, or in the operating room for elective or emergent surgical procedures with anesthesia.	Difficult tracheal intubation: https://browser.ihtsdotools.org/?perspective=full&conceptId1=718447001&… Difficult mask ventilation: https://browser.ihtsdotools.org/?perspective=full&conceptId1=763326004&… Mallampati scores: https://browser.ihtsdotools.org/?perspective=full&conceptId1=424296005&… Video intubation: (glidescope) https://browser.ihtsdotools.org/?perspective=full&conceptId1=870581009&… Intubation techniques: https://browser.ihtsdotools.org/?perspective=full&conceptId1=26412008&e… Difficult supraglottic airway ventilation https://browser.ihtsdotools.org/?perspective=full&conceptId1=766781004&…	Matthew Popovich	American Society of Anesthesiologists	09/29/2021 - 15:05
Level 1	Outcomes		Serious Adverse Events	An adverse event is any undesirable experience associated with the use of a medical product in a patient. A serious adverse event or reaction is any untoward medical occurrence that at any dose resulting in: Death Life-threatening Hospitalization (initial or prolonged) Disability or Permanent Damage Congenital Anomaly/Birth Defects Other Serious or Important Medical Events Required Intervention to Prevent Permanent Impairment/Damage	SNOMED CT (e.g., Life-threatening severity)	Mitra Rocca	Food and Drug Administration	09/30/2022 - 23:30
Level 1	Laboratory	Analysis of clinical specimens to obtain information about the health of a patient.	Instrument Unique Identifier	Uniquely identifies the type of instrument that was used in conjunction with the Test kit (at minimum by using instrument name and manufacturer (similar to the make and model of a car)) to obtain the Test Result Value. When a testkit is used on an instrument it is the combination of kit and instrument, that qualify the Performed Test.		Riki Merrick	Association of Public Health Laboratories	09/30/2021 - 22:25