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	Submitter Name	Submitter Organization	Submission Date
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	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. 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	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	Patient Demographics/Information	Data used to categorize individuals for identification, records matching, and other purposes.	Phone Number Type
USCDI V1	Care Team Members	Information about a person who participates or is expected to participate in the care of a patient.	Care Team Member
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	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	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	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	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.	History & Physical	Documents the current and past conditions and observations of the patient.	Logical Observation Identifiers Names and Codes (LOINC®) version 2.67 Discharge Summary (LOINC® code 34117-2)
USCDI V1	Patient Demographics/Information	Data used to categorize individuals for identification, records matching, and other purposes.	Email Address
Draft USCDI V2		Physiologic measurements of a patient that indicate the status of the body’s life sustaining functions.	Systolic Blood Pressure		Both standards are required. Logical Observation Identifiers Names and Codes (LOINC®) version 2.69 The Unified Code of Units for Measure (UCUM), Revision 2.1
Draft USCDI V2		Activity performed for or on a patient as part of the provision of care.	Procedures		Healthcare Common Procedure Coding System (HCPCS) Current Procedural Terminology (CPT), 2021 Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT®) U.S. Edition, September 2020 Release For technology primarily developed to record dental procedures: Code on Dental Procedures and Nomenclature (CDT), maintained and distributed by the American Dental Association, for dental services. Optional: International Classification of Diseases ICD-10-PCS 2021
Draft USCDI V2		The metadata, or extra information about data, regarding who created the data and when it was created.	Author Time Stamp
Draft USCDI V2		The metadata, or extra information about data, regarding who created the data and when it was created.	Author Organization	Organization associated with author.
Draft USCDI V2		Analysis of clinical specimens to obtain information about the health of a patient.	Tests	The name of the analysis of specimens derived from humans which provide information for the diagnosis, prevention, treatment of disease, or assessment of health.	Logical Observation Identifiers Names and Codes (LOINC®) version 2.69
Draft USCDI V2		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 2020 Release
Draft USCDI V2		Information related to interactions between healthcare providers and a patient.	Encounter Diagnosis		SNOMED International, Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT®) U.S. Edition, September 2020 Release International Classification of Diseases ICD-10-CM 2021	Joel Andress	Centers for Medicare and Medicaid Services (CMS) Center for Clinical Standards and Quality (CCSQ)	10/02/2020 - 08:35
Draft USCDI V2		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 2.69 The Unified Code of Units for Measure (UCUM), Revision 2.1