USCDI Export for the Public

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Classification Level Data Class Data Class Description Data Element Data Element Description Applicable Standards Submitter Name Submitter Organization Submission Date
Draft USCDI V2

Record of vaccine administration.

 Immunizations
  • CDC IIS: Current HL7 Standard Code Set, CVX -- Vaccines Administered, updates through November 16, 2020
  • CDC National Drug Code (NDC) Directory – Vaccine NDC Linker Table, updates through November 13, 2020
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

Physiologic measurements of a patient that indicate the status of the body’s life sustaining functions.

 Diastolic 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

Unique identifier(s) for a patient's implantable device(s).

 Marti Velezis FDA/CDRH/Indira Konduri (FDA/CDRH/OPEQ/ORP/DRPIII)
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)
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

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

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

The metadata, or extra information about data, regarding who created the data and when it was created.

 Author Time Stamp
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

Data used to categorize individuals for identification, records matching, and other purposes.

 Suffix
Draft USCDI V2

Data used to categorize individuals for identification, records matching, and other purposes.

 Race

Both standards are required

  • The Office of Management and Budget Standards for Maintaining, Collecting, and Presenting Federal Data on Race and Ethnicity, Statistical Policy Directive No. 15, as revised, October 30, 1997
  • CDC Race and Ethnicity Code Set Version 1.0 (March 2000)

Adopted at 45 CFR 170.207(f)
Draft USCDI V2

Data used to categorize individuals for identification, records matching, and other purposes.

 Date of Birth
Draft USCDI V2

Information about a person who participates or is expected to participate in the care of a patient.

 Care Team Member Identifier Al Taylor ONC
Draft USCDI V2

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:

  • Female. F
  • Male. M
  • Unknown. nullFlavor UNK

Adopted at 45 CFR 170.207(n) 
Draft USCDI V2

Data used to categorize individuals for identification, records matching, and other purposes.

 First Name
Draft USCDI V2

Data used to categorize individuals for identification, records matching, and other purposes.

 Previous Name
Draft USCDI V2

Health professional’s conclusions and working assumptions that will guide treatment of the patient.

 Assessment and Plan of Treatment
Draft USCDI V2

Data used to categorize individuals for identification, records matching, and other purposes.

 Last Name
Draft USCDI V2

Information about a person who participates or is expected to participate in the care of a patient.

 Care Team Member Name Al Taylor ONC