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 | Clinical Notes | Narrative patient data relevant to the context identified by note types.
|
Cause of Death | Cause of death information includes the sequence of events leading to death as well as other conditions significantly contributing to death. The underlying cause of death may be different than the terminal condition. This may include summary of death note, and/or death information that may be captured within the discharge summary note or other cause of death documentation within the clinical notes section. |
LOINC: Summary of death note: 47046-8: https://loinc.org/47046-8/ Physician Summary of death note: 83796-3: https://loinc.org/83796-3/ Nurse Summary of death note: 84273-2: https://loinc.org/84273-2/ US Standard Certificate of Death: https://www.cdc.gov/nchs/data/dvs/DEATH11-03final-ACC.pdf Hepatitis C Case Report Form: https://www.cdc.gov/hepatitis/pdfs/HepatitisCaseRprtForm.pdf Supporting Links: PHINVADS Value Set: https://phinvads.cdc.gov/vads/ViewValueSet.action?oid=2.16.840.1.114222.4.11.3593 |
Maria Michaels | CDC | |
| Level 0 | Clinical Notes | Narrative patient data relevant to the context identified by note types.
|
Summarization of encounter note narrative | A clinical note which narratively summarizes the patient encounter. LOINC code = 67781-5. |
LOINC https://loinc.org/67781-5/ https://loinc.org/28636-9/ https;//loinc.org/34108-1/ |
Nedra Garrett | Centers for Disease Control and Prevention | |
| Level 0 | Clinical Notes | Narrative patient data relevant to the context identified by note types.
|
Initial evaluation note | Initial evaluation note, LOINC code = 28636-9, and any LOINC LongName Note which has Initial Evaluation Note as a component. |
LOINC https://loinc.org/67781-5/ https://loinc.org/28636-9/ https;//loinc.org/34108-1/ |
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. |
HHS Disability Status - Cognitive | According to the HHS implementation guide there are six-item set of questions used on ACS and other major surveys to gauge disability is the data standard for survey questions on disability. (HHS Implementation Guidance on Data Collection Standards for Race, Ethnicity, Sex, Primary Language, and Disability Status | ASPE). https://aspe.hhs.gov/reports/hhs-implementation-guidance-data-collection-standards-race-ethnicity-sex-primary-language-disability-0 The prompt for this data element should be consistent with HHS implementation guide: “Because of a physical, mental, or emotional condition, do you have serious difficulty concentrating, remembering, or making decisions?” |
HL7 FHIR: US Public Health Disability Status HL7 CDA: Disability Status Observation VSAC Value Set: Disability Status (LOINC) |
Nedra Garrett | CDC | |
| Level 0 | Pregnancy Information | Number of Prenatal Visits | The total number of prenatal visits for the mother. |
LOINC codes exist for each of the proposed data elements: 68493-6: Prenatal visits for this pregnancy # 69044-6: Date first prenatal visit 69461-2 Mother's body weight --at delivery 73772-6 The number of fetal deaths this delivery 73773-4 - Number of infants in this delivery delivered alive 57722-1 - Birth plurality of Pregnancy |
Adam Bazer, MPD | Integrating the Healthcare Enterprise USA (IHE USA) | ||
| Level 0 | Pregnancy Information | Mother’s Delivery Weight | The weight of the mother at the time of birth/delivery. |
LOINC codes exist for each of the proposed data elements: 68493-6: Prenatal visits for this pregnancy # 69044-6: Date first prenatal visit 69461-2 Mother's body weight --at delivery 73772-6 The number of fetal deaths this delivery 73773-4 - Number of infants in this delivery delivered alive 57722-1 - Birth plurality of Pregnancy |
Adam Bazer, MPD | Integrating the Healthcare Enterprise USA (IHE USA) | ||
| Level 0 | Pregnancy Information | Mother’s Prepregnancy Weight | The weight of the mother before becoming pregnant. |
LOINC codes exist for each of the proposed data elements: Last menstrual period start date: 8665-2 Delivery date Estimated: 11778-8 Body weight --pre current pregnancy: 56077-1 |
Adam Bazer, MPD | Integrating the Healthcare Enterprise USA (IHE USA) | ||
| Level 0 | Pregnancy Information | Plurality | The number of fetuses delivered live or dead at any time in the pregnancy regardless of gestational age, or if the fetuses were delivered at different dates in the pregnancy. (“Reabsorbed” fetuses, those which are not “delivered” (expulsed or extracted from the mother) should not be counted.) Include all live births and fetal losses resulting from this pregnancy. |
LOINC codes exist for each of the proposed data elements: 68493-6: Prenatal visits for this pregnancy # 69044-6: Date first prenatal visit 69461-2 Mother's body weight --at delivery 73772-6 The number of fetal deaths this delivery 73773-4 - Number of infants in this delivery delivered alive 57722-1 - Birth plurality of Pregnancy |
Adam Bazer, MPD | Integrating the Healthcare Enterprise USA (IHE USA) | ||
| Level 0 | Work Information | Job Supervisory Level or Pay Grade | A coded term that indicates the responsibilities of a person’s job for directing work and managing personnel, as reported by the person. Pay grade is used for a military position, since it distinguishes between officers and enlisted service members and conveys similar meaning across all branches of service. |
Occupational Data for Health (Value Set -Job Supervisory Level or Pay Grade (ODH)) |
Nedra Garrett | CDC | ||
| 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. |
Incontinence | Lack of voluntary control over urination or defecation |
LOINC |
Holly Miller, MD | MedAllies | |
| 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. |
Accommodation | Provides information or details regarding modifications, tools, technologies, and/or other supports needed in order to address any barriers to care that an individual living with a disability(ies) may need in order to improve their care and life with a diagnosis. |
Grace Cordovano | Enlightening Results | ||
| Level 0 | Laboratory | Analysis of clinical specimens to obtain information about the health of a patient. |
Specimen collection date/time | Date/time when clinical specimen was collected from subject patient. | LOINC |
Nedra Garrett | Centers for Disease Control and Prevention | |
| Level 0 | Medical Devices | An instrument, machine, appliance, implant, software or other article intended to be used for a medical purpose. |
Oxygen Delivery Device | Specification of the method of oxygen delivery. Usage note: Provides critical context to understanding a patient's respiratory status, especially in light of the COVID-19 pandemic which predominantly causes illness with pneumonia. Examples include but are not limited to nasal cannula, face mask, non-rebreather, BIPAP, CPAP, and ventilator. This would provide critical additional context to understanding a patient's respiratory status, especially in light of the COVID-19 pandemic which predominantly causes illness with pneumonia. |
|
Joshua D. Geleris, MD | Columbia University Irving Medical Center | |
| 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. |
HHS Disability Status - Activities of Daily Living | According to the HHS implementation guide there are six-item set of questions used on ACS and other major surveys to gauge disability is the data standard for survey questions on disability. (HHS Implementation Guidance on Data Collection Standards for Race, Ethnicity, Sex, Primary Language, and Disability Status | ASPE). https://aspe.hhs.gov/reports/hhs-implementation-guidance-data-collection-standards-race-ethnicity-sex-primary-language-disability-0 The prompt for this data element should be consistent with HHS implementation guide: “Do you have difficulty dressing or bathing?” |
HL7 FHIR: US Public Health Disability Status HL7 CDA: Disability Status Observation VSAC Value Set: Disability Status (LOINC) |
Nedra Garrett | CDC | |
| Level 0 | Work Information | Job Employer Address | The self-reported Employer Address; this is not necessarily the work location. |
LOINC (r) 80429-4 Employer address |
Nedra Garrett | CDC | ||
| Level 0 | Medications | Pharmacologic agents used in the diagnosis, cure, mitigation, treatment, or prevention of disease. |
Medication Administration Status | A code specifying the status of the Administration of a drug. This would clearly identify the current status of the drug administration. At any time, some codes may be ambiguous, such as “in-progress”, in that it is not currently clear if the administration process moved forward. Other codes will provide definitive states of the administration. For instance, “completed” shows the administration was completed, while “entered-on-error” indicates the prescription process was halted and the administration did not move forward | In FHIR R4, https://www.hl7.org/fhir/medicationadministration-definitions.html#MedicationAdministration.status |
Scott Gordon | Food and Drug Administration | |
| Level 0 | Work Information | Job Start Date | The date a person started working in a Job. | Nedra Garrett | CDC | |||
| Level 0 | Work Information | Job End Date | The last day a person worked in a Job. | Nedra Garrett | CDC | |||
| Level 0 | Work Information | Job Employer Name | The company, organization, or individual that provides compensation for a job or that assigns work to a volunteer, as reported by the person. For a military position, this is the self-reported duty station (home base). |
LOINC® 80427-8 Employer name |
Nedra Garrett | CDC | ||
| 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. |
HHS Disability Status - Mobility | According to the HHS implementation guide there are six-item set of questions used on ACS and other major surveys to gauge disability is the data standard for survey questions on disability. (HHS Implementation Guidance on Data Collection Standards for Race, Ethnicity, Sex, Primary Language, and Disability Status | ASPE). https://aspe.hhs.gov/reports/hhs-implementation-guidance-data-collection-standards-race-ethnicity-sex-primary-language-disability-0 The prompt for this data element should be consistent with HHS implementation guide: “Do you have serious difficulty walking or climbing stairs?” https://aspe.hhs.gov/reports/hhs-implementation-guidance-data-collection-standards-race-ethnicity-sex-primary-language-disability-0 |
HL7 FHIR: US Public Health Disability Status HL7 CDA: Disability Status Observation VSAC Value Set: Disability Status (LOINC) |
Nedra Garrett | CDC |