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 | Nutrition and Diet | Enteral Nutrition Frequency | Scheduled frequency of enteral feeding. This data element must be provided in conjunction with the Enteral Nutrition Type and other Enteral Nutrition data elements. | HL7 Version 2 – ODS – Dietary orders, supplements, and preferences (http://www.hl7.org/implement/standards/product_brief.cfm?product_id=185) HL7 Version 3 Standard: Orders; Diet and Nutrition, Release 1 (http://www.hl7.org/implement/standards/product_brief.cfm?product_id=317) HL7 FHIR NutritionOrder (https://www.hl7.org/fhir/nutritionorder.html) In addition, many there are many nutrition-related terms in SNOMED CT. Many of these terms have been put in value sets in VSAC or through HL7 terminology. Here are some examples: Diet Type (OID 2.16.840.1.113883.4.642.3.385) – HL7 terminology Nutrient Modifier (OID 2.16.840.1.113883.4.642.3.386) – HL7 terminology Nutrition Supplement (OID 2.16.840.1.113883.4.642.3.390) – HL7 terminology Enteral Nutrition Type (OID 2.16.840.1.113883.4.642.3.391) – HL7 terminology Enteral Nutrition Additive (OID 2.16.840.1.113883.4.642.3.392) – HL7 terminology Food Allergies and Intolerance (OID 2.16.840.1.113762.1.4.1186.3) - VSAC Feeding Device Grouping (OID 2.16.840.1.113762.1.4.1095.87) - VSAC |
Becky Gradl | Academy of Nutrition and Dietetics | ||
| Level 0 | Nutrition and Diet | Enteral Nutrition Additive | Type of modular component to add to the enteral nutrition feeding. This data element must be provided in conjunction with the Enteral Nutrition Type and other Enteral Nutrition data elements. | HL7 Version 2 – ODS – Dietary orders, supplements, and preferences (http://www.hl7.org/implement/standards/product_brief.cfm?product_id=185) HL7 Version 3 Standard: Orders; Diet and Nutrition, Release 1 (http://www.hl7.org/implement/standards/product_brief.cfm?product_id=317) HL7 FHIR NutritionOrder (https://www.hl7.org/fhir/nutritionorder.html) In addition, many there are many nutrition-related terms in SNOMED CT. Many of these terms have been put in value sets in VSAC or through HL7 terminology. Here are some examples: Diet Type (OID 2.16.840.1.113883.4.642.3.385) – HL7 terminology Nutrient Modifier (OID 2.16.840.1.113883.4.642.3.386) – HL7 terminology Nutrition Supplement (OID 2.16.840.1.113883.4.642.3.390) – HL7 terminology Enteral Nutrition Type (OID 2.16.840.1.113883.4.642.3.391) – HL7 terminology Enteral Nutrition Additive (OID 2.16.840.1.113883.4.642.3.392) – HL7 terminology Food Allergies and Intolerance (OID 2.16.840.1.113762.1.4.1186.3) - VSAC Feeding Device Grouping (OID 2.16.840.1.113762.1.4.1095.87) - VSAC |
Becky Gradl | Academy of Nutrition and Dietetics | ||
| 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 right eye | Same as above |
LOINC |
Kerry Goetz | NIH/NEI | |
| Level 0 | Social Determinants of Health | Self-Identified Need for Contraception (SINC) | Self-Identified Need for Contraception screening tool for primary care settings. |
Self-Identified Need for Contraception (SINC) LOINC: 98076-3 |
Dr. Christine Dehlendorf | Person-Centered Reproductive Health Program, Family and Community Medicine, University of California, San Francisco | ||
| 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 | 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 | 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 right 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 | |
| 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 | 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. |
Refraction | A refraction test is what the doctor uses to get your eyeglasses prescription. You look at a chart, usually 20 feet away, or in a mirror that makes things look like they’re 20 feet away. You’ll look through a tool called a phoropter. It lets the doctor move lenses of different strengths in front of your eyes. The test also helps your doctor spot presbyopia, hyperopia, myopia, and astigmatism. Source: WebMD Glossary of Eye Tests and Exams LOINC Panel 79895-9 |
LOINC Panel 79895-9 Subjective refraction measurements panel |
Kerry Goetz | NIH/NEI | |
| Level 0 | Referral | Referral requestor | The individual who initiated the request and has responsibility for its activation. |
Routine Interfacility Patient Transport (RIPT) - https://www.ihe.net/uploadedFiles/Documents/PCC/IHE_PCC_Suppl_RIPT.pdf https://hl7.org/fhir/R4/servicerequest.html |
Adam Bazer, MPD | Integrating the Healthcare Enterprise USA (IHE USA) | ||
| Level 0 | Nutrition and Diet | Eating/drinking assistive device | External devices that are designed, made, or adapted to assist a person with eating and/or drinking | HL7 Version 2 – ODS – Dietary orders, supplements, and preferences (http://www.hl7.org/implement/standards/product_brief.cfm?product_id=185) HL7 Version 3 Standard: Orders; Diet and Nutrition, Release 1 (http://www.hl7.org/implement/standards/product_brief.cfm?product_id=317) HL7 FHIR NutritionOrder (https://www.hl7.org/fhir/nutritionorder.html) In addition, many there are many nutrition-related terms in SNOMED CT. Many of these terms have been put in value sets in VSAC or through HL7 terminology. Here are some examples: Diet Type (OID 2.16.840.1.113883.4.642.3.385) – HL7 terminology Nutrient Modifier (OID 2.16.840.1.113883.4.642.3.386) – HL7 terminology Nutrition Supplement (OID 2.16.840.1.113883.4.642.3.390) – HL7 terminology Enteral Nutrition Type (OID 2.16.840.1.113883.4.642.3.391) – HL7 terminology Enteral Nutrition Additive (OID 2.16.840.1.113883.4.642.3.392) – HL7 terminology Food Allergies and Intolerance (OID 2.16.840.1.113762.1.4.1186.3) - VSAC Feeding Device Grouping (OID 2.16.840.1.113762.1.4.1095.87) - VSAC |
Becky Gradl | Academy of Nutrition and Dietetics | ||
| Level 0 | Patient Demographics/Information | Data used to categorize individuals for identification, records matching, and other purposes. |
Multiple Birth Order | If not a single birth then the order born in the delivery, live born or fetal death (1st, 2nd, 3rd, 4th, 5th, 6th, 7th, etc.). |
FHIR patient extension: birthplace FHIR patient address.period |
Adam Bazer, MPD | Integrating the Healthcare Enterprise USA (IHE USA) | |
| Level 0 | Referral | Referral coverage | Insurance plans, coverage extensions, pre-authorizations and/or pre-determinations that may be needed for delivering the requested service. |
Routine Interfacility Patient Transport (RIPT) - https://www.ihe.net/uploadedFiles/Documents/PCC/IHE_PCC_Suppl_RIPT.pdf https://hl7.org/fhir/R4/servicerequest.html |
Adam Bazer, MPD | Integrating the Healthcare Enterprise USA (IHE USA) | ||
| Level 0 | Referral | Referral code | A code that identifies a particular service (i.e., procedure, diagnostic investigation, or panel of investigations) that have been requested. |
Routine Interfacility Patient Transport (RIPT) - https://www.ihe.net/uploadedFiles/Documents/PCC/IHE_PCC_Suppl_RIPT.pdf https://hl7.org/fhir/R4/servicerequest.html |
Adam Bazer, MPD | Integrating the Healthcare Enterprise USA (IHE USA) | ||
| 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 | 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 |