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 |
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| USCDI V1 | Clinical Notes | Narrative patient data relevant to the context identified by note types.
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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
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| 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.
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| USCDI V1 | Procedures | Activity performed for or on a patient as part of the provision of care. |
Procedures |
Optional:
Optional for technology which records dental procedures:
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| USCDI V1 | Vital Signs | Physiologic measurements of a patient that indicate the status of the body’s life sustaining functions. |
Heart Rate |
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| USCDI V1 | Vital Signs | Physiologic measurements of a patient that indicate the status of the body’s life sustaining functions. |
Respiratory Rate |
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| 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) |
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Marti Velezis | FDA/CDRH/Indira Konduri (FDA/CDRH/OPEQ/ORP/DRPIII) | ||
| USCDI V1 | Provenance | The metadata, or extra information about data, regarding who created the data and when it was created. |
Author Organization | Organization associated with author. |
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| USCDI V1 | Problems | Condition, diagnosis, or reason for seeking medical attention. |
Problems |
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| USCDI V1 | Clinical Notes | Narrative patient data relevant to the context identified by note types.
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History & Physical | Documents the current and past conditions and observations of the patient. |
Logical Observation Identifiers Names and Codes (LOINC®) version 2.67
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| USCDI V1 | Vital Signs | Physiologic measurements of a patient that indicate the status of the body’s life sustaining functions. |
Body Temperature |
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| 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 | Vital Signs | Physiologic measurements of a patient that indicate the status of the body’s life sustaining functions. |
Pulse Oximetry |
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| Draft USCDI V2 | 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.
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| Draft USCDI V2 | Assessment and Plan of Treatment | Health professional’s conclusions and working assumptions that will guide treatment of the patient. |
Assessment and Plan of Treatment | |||||
| Draft USCDI V2 | Problems | Condition, diagnosis, or reason for seeking medical attention. |
Date of Diagnosis | Date of first determination by a qualified professional of the presence of a problem or condition affecting a patient. |
Steven Lane | Sutter Health | ||
| Draft USCDI V2 | Provenance | The metadata, or extra information about data, regarding who created the data and when it was created. |
Author Time Stamp | |||||
| Draft USCDI V2 | Encounter Information | Information related to interactions between healthcare providers and a patient. |
Encounter Diagnosis |
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Joel Andress | Centers for Medicare and Medicaid Services (CMS) Center for Clinical Standards and Quality (CCSQ) | ||
| Draft USCDI V2 | Patient Demographics/Information | Data used to categorize individuals for identification, records matching, and other purposes. |
Phone Number | Both standards are required
Adopted at 45 CFR 170.207(q)(1) |
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| Draft USCDI V2 | Smoking Status | Representing a patient’s smoking behavior. |
Smoking Status | Representing a patient’s smoking behaviors. |
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| Draft USCDI V2 | Patient Demographics/Information | Data used to categorize individuals for identification, records matching, and other purposes. |
Sex (Assigned at Birth) | Birth sex must be coded in accordance with HL7 Version 3 (V3) Standard, Value Sets for AdministrativeGender and NullFlavor attributed as follows:
Adopted at 45 CFR 170.207(n) |