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 |
|---|---|---|---|---|---|---|---|---|
| Level 0 | Immunizations | Record of vaccine administration. |
Reason Immunization Not Performed | Indicates the reason the immunization event was not performed. |
Immunization Code: CVX: Vaccines Administered 2.16.840.1.113762.1.4.1010.6: https://vsac.nlm.nih.gov/valueset/2.16.840.1.113762.1.4.1010.6/expansion Immunization Code: National Drug Codes (NDC): http://www2a.cdc.gov/vaccines/iis/iisstandards/ndc_tableaccess.asp Immunization Status: FHIR Immunization Status Codes: http://hl7.org/fhir/ValueSet/immunization-status Immunization Administered Date: FHIR datatypes: dateTime, String: https://www.hl7.org/fhir/us/core/StructureDefinition-us-core-immunization-definitions.html#Immunization.occurrence[x] Reason Immunization Not Performed: FHIR Immunization Status Reason Codes: http://hl7.org/fhir/R4/valueset-immunization-status-reason.html |
Maria Michaels | CDC | |
| Level 0 | Outcomes | Oncology Adverse events | complications (serious- hospitalization, death) |
Laura Esserman | University of California - San Francisco | |||
| Level 0 | Immunizations | Record of vaccine administration. |
Vaccination Administration Date | The date the vaccination event occurred. |
LOINC:30952-6- Date and time of vaccination: https://loinc.org/30952-6/ |
Nedra Garrett | Centers for Disease Control and Prevention | |
| Level 0 | Travel Information | Travel Plans Dates | Dates planned for travel to a location. |
Geographical location history (https://phinvads.cdc.gov/vads/ViewValueSet.action?oid=2.16.840.1.114222.4.11.3201) ISO 3166 country codes (https://www.iso.org/iso-3166-country-codes.html) |
Craig Newman | Altarum | ||
| Level 0 | Travel Information | Travel Plans Location | Represents a location in a person’s travel plans (either an address or a coded location). |
§ SNOMED: 420008001 |Travel (event)| § Geographical location history (https://phinvads.cdc.gov/vads/ViewValueSet.action?oid=2.16.840.1.114222.4.do 11.3201) § ISO 3166 country codes (https://www.iso.org/iso-3166-country-codes.html) § NCI_Thesaurus 22.08e: code C173619 § LOINC v2.72 code: PhenX measure - international travel history:-:Pt:^Patient:-:PhenX (Code 62887-5) |
Craig Newman | Altarum | ||
| Level 0 | Cancer Care | Oncology Outcomes | response to therapy – minimal residual disease, complete pathologic response)- local recurrence, distant recurrence |
Laura Esserman | University of California - San Francisco | |||
| Level 0 | Pregnancy Information | Gestational Age | "The estimated gestational age (in weeks, or weeks and fraction of week) of the pregnancy at the time of the health care encounter (in contrast to the gestational age at birth), beginning from the time of fertilization. Needs to be correlated with the date the gestational age was documented. Gestational age (written with both weeks and days) is calculated using the best obstetrical estimated delivery date (EDD) based on the following formula: Gestational Age = (280 - (EDD - Reference Date))/ 7" |
https://www.hl7.org/implement/standards/product_brief.cfm?product_id=494 |
Nedra Garrett | Centers for Disease Control and Prevention | ||
| Level 0 | 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. |
ECOG | The Eastern Cooperative Oncology Group (ECOG) Performance Status represents the patient's functional status and is used to determine how a disease impacts a patient’s daily living abilities and their overall ability to tolerate therapies in serious illness, specifically for chemotherapy. |
LOINC, SNOMED-CT, and FHIR see: https://search.loinc.org/searchLOINC/search.zul?query=functional+status http://hl7.org/fhir/us/mcode/ https://browser.ihtsdotools.org/?perspective=full&conceptId1=273472005&edition=MAIN/2020-07-31&release=&languages=en |
Andre Quina | MITRE | |
| Level 0 | Pregnancy Information | Multiple Gestation | Multiple gestation is pregnancy with more than one baby at a time. Examples include pregnancy with twins, triplets, and quadruplets. Multiple gestation is a type of high-risk pregnancy that occurs in approximately three percent of pregnancies. |
SNOMED CT 16356006 Multiple pregnancy (disorder) LOINC 45371-2 Multiple pregnancy |
Andrea Fourquet | IHE USA | ||
| Level 0 | Pregnancy Information | Corrected Estimated Due Date | The Estimated Due Date that has been corrected during the period before birth. |
LOINC 57060-6 Estimated date of delivery Narrative 11778-8 Delivery date Estimated 53692-0 Delivery date Estimated from conception date 11780-4 Delivery date Estimated from ovulation date 57063-0 Delivery date Estimated from quickening date 90368-2 Delivery date Estimated from physical exam 57064-8 Delivery date Estimated from date fundal height reaches umb 11779-6 Delivery date Estimated from last menstrual period 53694-6 Delivery date Estimated from prior gestational age assessment SNOMED CT 161714006 | Estimated date of delivery (observable entity) 289206005 | Estimated date of delivery from last period (observable entity) 33714007 | Corrected (qualifier value) |
Andrea Fourquet | IHE USA | ||
| Level 0 | Pregnancy Information | Planned Pregnancy | Assessing patients for planned pregnancy information reduces the risk of adverse health effects for the woman, fetus, and neonate by working with the woman to optimize health, address modifiable risk factors, provide education and interventions. |
SNOMED CT |
Andrea Fourquet | IHE USA | ||
| Level 0 | Medications | Pharmacologic agents used in the diagnosis, cure, mitigation, treatment, or prevention of disease. |
Therapeutic Medication Response | Represents a therapeutic response (as opposed to an undesired reaction) to the administration of a medication. |
HL7 FHIR: Therapeutic Medication Response extension HL7 CDA: Therapeutic Medication Response observation LOINC: 67540-5 "Response to medication" VSAC Value Set: Therapeutic Response to Medication |
Laura Conn | ||
| Level 0 | Explanation of Benefit | Health data as reflected in a patient's Explanation of Benefits (EOB) statements, typically derived from claims and other administrative data. |
Copay Amount | Amount an insured individual pays directly to a provider at the time the services or supplies are rendered. Usually, a copay will be a fixed amount per service, such as $15.00 per office visit. |
NUBC, CPT, HCPCS, HIPPS, ICD-9, ICD-10, DRGs, NDC, POS, NCPDP codes, and X12 codes. |
Mark Roberts | Leavitt Partners | |
| Level 0 | Pregnancy Information | Estimated Date of Delivery | The expected date of delivery (i.e. the due date). |
LOINC codes exist for each of the proposed data elements: 8665-2 - Last menstrual period start date 11778-8 - Delivery date Estimated 56077-1 - Body weight --pre current pregnancy |
Craig Newman | Altarum | ||
| Level 0 | Pregnancy Information | Last Menstrual Period (LMP) | Date of the first day of the last menstrual period. |
LOINC : 8665-2 Last menstrual period start date IHE 1.3.6.1.4.1.19376.1.5.3.1.3.18 HL7 FHIR observation - https://www.hl7.org/fhir/observation-example-date-lastmp.html CMS - https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/dwnlds/R81CPpdf.pdf (Pg. 4, ) |
Andrea Fourquet | IHE USA | ||
| Level 0 | Clinical Notes | Narrative patient data relevant to the context identified by note types.
|
Antepartum Summary Note | The Antepartum Summary Note defines the aggregation of significant events, diagnoses, and plans of care derived from the visits over the course of an antepartum episode. It is a summary of the most critical information antepartum care providers capture and share regarding the status of a patient’s pregnancy. It is represented in part by Estimated Due Dates and summaries of the various antepartum visits. The information is aggregated data from which the patient’s interactions with care providers are captured. It includes data such as the patient’s allergies, advance directives, care planning, and selected histories. The antepartum summary 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 276986009 Antepartum LOINC: 57061-4 Antepartum flowsheet panel Narrative https://loinc.org/57061-4/ 57055-6 Antepartum summary note https://loinc.org/57055-6/ ICD9 CM Complications of Pregnancy, Childbirth and the Puerperium http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.111.11.1021 ICD10CM, SNOMEDCT Complications of Pregnancy, Childbirth and the Puerperium http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.111.12.1012 Pregnancy https://vsac.nlm.nih.gov/valueset/2.16.840.1.113883.3.526.3.378/expansion |
Andrea Fourquet | IHE USA | |
| Level 0 | Medications | Pharmacologic agents used in the diagnosis, cure, mitigation, treatment, or prevention of disease. |
Medication Administered Reason Reference | Reference to a condition that is the reason for the medication administration. |
Date Medication Prescribed and Date Medication Administered: dateTime Data Type (FHIR): http://hl7.org/fhir/datatypes.html#dateTime Medication Prescribed Code and Medication Administered Code: RxNorm: https://www.nlm.nih.gov/research/umls/rxnorm/index.html Medication Prescribed Dose Units and Medication Administration Dose Units: UCUM: http://unitsofmeasure.org |
Maria Michaels | CDC | |
| Level 0 | Medications | Pharmacologic agents used in the diagnosis, cure, mitigation, treatment, or prevention of disease. |
Medication Administration Dose | The amount of the medication given at one administration event. |
Date Medication Prescribed and Date Medication Administered: dateTime Data Type (FHIR): http://hl7.org/fhir/datatypes.html#dateTime Medication Prescribed Code and Medication Administered Code: RxNorm: https://www.nlm.nih.gov/research/umls/rxnorm/index.html Medication Prescribed Dose Units and Medication Administration Dose Units: UCUM: http://unitsofmeasure.org |
Maria Michaels | CDC | |
| Level 0 | Medications | Pharmacologic agents used in the diagnosis, cure, mitigation, treatment, or prevention of disease. |
Medication Administration Dose Units | The units of measure associated with the amount of medication given at one administration event |
Date Medication Prescribed and Date Medication Administered: dateTime Data Type (FHIR): http://hl7.org/fhir/datatypes.html#dateTime Medication Prescribed Code and Medication Administered Code: RxNorm: https://www.nlm.nih.gov/research/umls/rxnorm/index.html Medication Prescribed Dose Units and Medication Administration Dose Units: UCUM: http://unitsofmeasure.org |
Maria Michaels | CDC | |
| Level 0 | Medications | Pharmacologic agents used in the diagnosis, cure, mitigation, treatment, or prevention of disease. |
Medication Administered Code | A code (or set of codes) that specify the medication that was administered. |
Date Medication Prescribed and Date Medication Administered: dateTime Data Type (FHIR): http://hl7.org/fhir/datatypes.html#dateTime Medication Prescribed Code and Medication Administered Code: RxNorm: https://www.nlm.nih.gov/research/umls/rxnorm/index.html Medication Prescribed Dose Units and Medication Administration Dose Units: UCUM: http://unitsofmeasure.org |
Maria Michaels | CDC |