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 | Medical Devices | An instrument, machine, appliance, implant, software or other article intended to be used for a medical purpose. |
Ventilator Mode | The mode of mechanical ventilation if the patient is receiving mechanical ventilation. Could refer to LOINV 20124-4 for options. |
Airway type LOINC LL5542-7 |
Ali Abbasi MD- on behalf of the I-SPY COVID investigators | I-SPY COVID Trial Investigators | |
| Level 0 | Clinical Tests | Non-imaging and non-laboratory tests performed that result in structured or unstructured findings specific to the patient to facilitate the diagnosis and management of conditions. |
Intraocular pressure | Intraocular pressure (IOP) is the fluid pressure inside the eye. Tonometry is the method eye care professionals use to determine the IOP. IOP is an important aspect in the evaluation of patients at risk for glaucoma. Most tonometers are calibrated to measure pressure in millimeters of mercury (mmHg). Source: Regenstrief LOINC |
LOINC part LP96294-1 Right eye 79892-6 Left eye 79893-4 |
Kerry Goetz | NIH/NEI | |
| Level 0 | Clinical Tests | Non-imaging and non-laboratory tests performed that result in structured or unstructured findings specific to the patient to facilitate the diagnosis and management of conditions. |
Right eye Intraocular pressure | Intraocular pressure (IOP) is the fluid pressure inside the eye. Tonometry is the method eye care professionals use to determine the IOP. IOP is an important aspect in the evaluation of patients at risk for glaucoma. Most tonometers are calibrated to measure pressure in millimeters of mercury (mmHg). Source: Regenstrief LOINC LOINC- 79892-6 |
LOINC part LP96294-1 Right eye 79892-6 Left eye 79893-4 |
Kerry Goetz | NIH/NEI | |
| Level 0 | Medications | Pharmacologic agents used in the diagnosis, cure, mitigation, treatment, or prevention of disease. |
Medication Prescribed Dose | Indicates the amount of medication per dose that is to be used by the patient. |
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 | Medical Devices | An instrument, machine, appliance, implant, software or other article intended to be used for a medical purpose. |
Ventilator measured plateau pressure | The measured plateau pressure on the ventilator if the patient is receiving mechanical ventilation |
Airway type LOINC LL5542-7 |
Ali Abbasi MD- on behalf of the I-SPY COVID investigators | I-SPY COVID Trial Investigators | |
| Level 0 | Medical Devices | An instrument, machine, appliance, implant, software or other article intended to be used for a medical purpose. |
Measured ventilator peak inspiratory pressure | Measured peak inspiratory pressure if the patient is receiving mechanical ventilation |
Airway type LOINC LL5542-7 |
Ali Abbasi MD- on behalf of the I-SPY COVID investigators | I-SPY COVID Trial Investigators | |
| Level 0 | Medical Devices | An instrument, machine, appliance, implant, software or other article intended to be used for a medical purpose. |
Medical Device Name | The name of the medical device. |
Sandi Mitchell | J P Systems, Inc. | ||
| Level 0 | Clinical Tests | Non-imaging and non-laboratory tests performed that result in structured or unstructured findings specific to the patient to facilitate the diagnosis and management of conditions. |
Left eye Intraocular pressure | Intraocular pressure (IOP) is the fluid pressure inside the eye. Tonometry is the method eye care professionals use to determine the IOP. IOP is an important aspect in the evaluation of patients at risk for glaucoma. Most tonometers are calibrated to measure pressure in millimeters of mercury (mmHg). Source: Regenstrief LOINC LOINC- 79893-4 |
LOINC part LP96294-1 Right eye 79892-6 Left eye 79893-4 |
Kerry Goetz | NIH/NEI | |
| Level 0 | Clinical Tests | Non-imaging and non-laboratory tests performed that result in structured or unstructured findings specific to the patient to facilitate the diagnosis and management of conditions. |
Visual acuity logMAR left eye | Same as above |
LOINC |
Kerry Goetz | NIH/NEI | |
| Level 0 | Medical Devices | An instrument, machine, appliance, implant, software or other article intended to be used for a medical purpose. |
Device Settings | Patient-specific settings associated with a device. |
Device Type: SNOMED (Implanted port-central lines and tunneled hemodialysis catheters; Non-implantable devices would include ventilators, temporary central lines, urinary catheters) Location of Device Initiation: HSLOC code system (https://www.cdc.gov/nhsn/cdaportal/terminology/codesystem/hsloc.html) Device Settings: LOINC (fraction of inspired oxygen, pressure support, positive end-expiratory pressure, ventilator mode, tidal volume delivered, frequency/respiratory rate setting - delivered by the ventilator) Device Observations / Measurements: LOINC (peak pressure, plateau pressure, spontaneous tidal volume, respiratory rate - spontaneous that the patient breaths) Device Route: type of airway (nasal cannula, facemask, endotracheal tube, tracheostomy) - delivery, approach - Feedback requested Device Status: related value sets: http://hl7.org/fhir/R4/valueset-device-status.html (active, inactive) or http://hl7.org/fhir/ValueSet/metric-operational-status (on, off, standby) - weaning trial - may be a property of the Procedure - Feedback requested |
Sheila Abner | CDC/NHSN | |
| Level 0 | Problems | Condition, diagnosis, or reason for seeking medical attention. |
Disease Trend | Disease trend, also referred to as disease status, represents the clinician's overall judgment on the current trend of a condition, e.g., whether it is stable, worsening (progressing), or improving (responding). The judgment may be based a single type or multiple kinds of evidence, such as imaging data, physical examination, tumor measurements, laboratory data, etc. The condition trend can be reported multiple times during the course of a condition, each report representing the clinical judgement at that point in time. The element is important in assessing disease progression and determining the efficacy of treatments. |
HL7 FHIR Implementation Guide: minimal Common Oncology Data Elements (mCODE) Release 1 - US Realm | STU1 |
Andre Quina | MITRE | |
| 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. |
Mobility | This data element carries information on Mobility that is exchanged as observations. (Observations are characteristics that can be tested, measured, or observed and are communicated with a name-value pair structure). Mobility is a broad domain. Using the conceptual framework of the International Classification of Function (ICF), it includes aspects such as rolling over, transferring, walking short distances, etc. Notes: • This data element is constrained to health data represented in data structures for observations. Observations should be represented using terminologies supporting this conceptual model, such as LOINC, which is designed for this purpose. Representing problems, goals, and other types of information related to functioning should use other data class structures as appropriate. • Examples of Mobility concepts can be found in the ICF browser at: https://apps.who.int/classifications/icfbrowser • Examples of demonstrated use of Mobility data can be found in the PACIO FHIR Functional Status Implementation Guide which supports exchange of observation data such as roll left and right, car transfer, walk 10 feet using assessments coded with LOINC. |
LOINC. LOINC is a freely available global standard that contains a well-developed model for representing variables, answer lists, and the collections that contain them.* Many clinical assessments, scales, and other observations related to functioning are present in LOINC, including all of the variables on the PAC assessments for SNFs, IRFs, LTCHs, and HHAs. Regenstrief operates a robust process for adding new content (including functioning assessment instruments) if key gaps are identified. *PMID: 22899966 |
Michelle Dougherty | Submitted on behalf of the CMS Data Element Library (DEL) Health IT Workgroup | |
| 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. |
Nutrition Status | A systematic nutrition assessment of an individual's nutrition intake, physical exam, anthropometric measurements, biochemical, and health condition data compared to accepted standards, recommendations, and/or goals to arrive at a determination of the client’s nutrition well-being or malnutrition. |
LOINC 75304-6 Nutrition status observation panel |
Michelle Ashafa | Academy of Nutrition and Dietetics | |
| Level 0 | Medical Devices | An instrument, machine, appliance, implant, software or other article intended to be used for a medical purpose. |
Medical Device Use | The use of the medical device. |
Sandi Mitchell | J P Systems, Inc. | ||
| Level 0 | Patient Summary and Plan | Information that guides treatment of the patient and recommendations for future treatment. |
Treatment Change | Treatment Change documents the reason for changes to the plan of treatment plan. The options for this data element are, for example: no change (continue treatment), planned change, no response to treatment, adverse reaction, patient request for alternative treatment. The first option (no change in treatment plan) can document a review of the treatment plan that did not require in a change of treatment. |
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 | Medications | Pharmacologic agents used in the diagnosis, cure, mitigation, treatment, or prevention of disease. |
Date Medication Prescribed | The date when the prescription was initially written or authored. |
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 | Clinical Tests | Non-imaging and non-laboratory tests performed that result in structured or unstructured findings specific to the patient to facilitate the diagnosis and management of conditions. |
Visual acuity corrected right eye | Same as above |
LOINC |
Kerry Goetz | NIH/NEI | |
| Level 0 | Medications | Pharmacologic agents used in the diagnosis, cure, mitigation, treatment, or prevention of disease. |
Medication Prescribed Code | A code (or set of codes) that specify this medication, or a textual description if no code is available. |
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 | Clinical Tests | Non-imaging and non-laboratory tests performed that result in structured or unstructured findings specific to the patient to facilitate the diagnosis and management of conditions. |
Visual acuity corrected left eye | Same as above |
LOINC |
Kerry Goetz | NIH/NEI | |
| Level 0 | Clinical Tests | Non-imaging and non-laboratory tests performed that result in structured or unstructured findings specific to the patient to facilitate the diagnosis and management of conditions. |
Visual acuity uncorrected left eye | Same as above |
LOINC |
Kerry Goetz | NIH/NEI |