USCDI Export for the Public

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Classification Level Sort descending	Data Class Description	Data Element	Data Element Description	Applicable Standards	Submitter Name	Submitter Organization	Submission Date
Draft USCDI V3	Health professional’s conclusions and working assumptions that will guide treatment of the patient.	Assessment and Plan of Treatment
Draft USCDI V3	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.	Health Concerns
Draft USCDI V3	Information about a person who participates or is expected to participate in the care of a patient.	Care Team Member Role			Al Taylor	ONC	10/10/2020 - 02:26
Draft USCDI V3	Pharmacologic agents used in the diagnosis, cure, mitigation, treatment, or prevention of disease.	Medications		RxNorm® Full Monthly Release, January 3, 2022
Draft USCDI V3	Data used to categorize individuals for identification, records matching, and other purposes.	Phone Number		Both standards are required ITU-T E.123, Series E: Overall Network Operation, Telephone Service, Service Operation and Human Factors, International operation - General provisions concerning users: Notation for national and international telephone numbers, email addresses and web addresses, February 2001 ITU-T E.164, Series E: Overall Network Operation, Telephone Service, Service Operation and Human Factors, International operation - Numbering plan of the international telephone service, The international public telecommunication numbering plan, November 2010 Adopted at 45 CFR 170.207(q)(1)
Draft USCDI V3	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 2.71 The Unified Code of Units for Measure, Revision 2.1
Draft USCDI V3	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 2.71 Procedure Note (LOINC® code 28570-0)
Draft USCDI V3	Physiologic measurements of a patient that indicate the status of the body’s life sustaining functions.	Pulse Oximetry		Logical Observation Identifiers Names and Codes (LOINC®) version 2.71 The Unified Code of Units for Measure, Revision 2.1
Draft USCDI V3	Information related to interactions between healthcare providers and a patient.	Encounter Type			Joel Andress	Centers for Medicare and Medicaid Services (CMS) Center for Clinical Standards and Quality (CCSQ)	10/02/2020 - 08:35
Draft USCDI V3	Data used to categorize individuals for identification, records matching, and other purposes.	Sexual Orientation	A person’s identification of their emotional, romantic, sexual, or affectional attraction to another person	Sexual orientation must be coded in accordance with SNOMED CT® and HL7 Version 3 Standard, Value Sets for AdministrativeGender and NullFlavor, attributed as follows: Lesbian, gay or homosexual. 38628009 Straight or heterosexual. 20430005 Bisexual. 42035005 Something else, please describe. nullFlavor OTH Don't know. nullFlavor UNK Choose not to disclose. nullFlavor ASKU Adopted at 45 CFR 170.207(o)(1)	A. Taylor	ONC	10/09/2020 - 23:18
Draft USCDI V3	Activity performed for or on a patient as part of the provision of care.	Procedures		SNOMED International, Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT®) U.S. Edition, January 2022 Release Current Procedural Terminology (CPT®) 2021, as maintained and distributed by the American Medical Association, for physician services and other health care services, and Healthcare Common Procedure Coding System (HCPCS), as maintained and distributed by HHS. 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 V3	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 2.71 The Unified Code of Units for Measure, Revision 2.1
Draft USCDI V3	Data used to categorize individuals for identification, records matching, and other purposes.	Previous Address	Includes street name, number, city/town, state, and zip code.
Draft USCDI V3	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.	Mental Function	Represents observations related to a patient's current level of cognitive functioning, including alertness, orientation, comprehension, concentration, and immediate memory for simple commands.	Logical Observation Identifiers Names and Codes (LOINC®) version 2.71	Michelle Dougherty	Submitted on behalf of the CMS Data Element Library (DEL) Health IT Workgroup	10/23/2020 - 16:50
Draft USCDI V3	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 2.71 Discharge Summary (LOINC® code 34117-2)
Draft USCDI V3	Data used to categorize individuals for identification, records matching, and other purposes.	Last Name
Draft USCDI V3	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 V3	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, January 2022 Release
Draft USCDI V3	Activity performed for or on a patient as part of the provision of care.	Reason for Referral	An explanation or justification for why this service is being requested or was provided.		Adam Bazer, MPD	Integrating the Healthcare Enterprise USA (IHE USA)	10/23/2020 - 21:31
Draft USCDI V3	Data used to categorize individuals for identification, records matching, and other purposes.	Gender Identity	A person’s internal sense of being a man, woman, both, or neither.	Gender Identify must be coded in accordance with SNOMED CT® and HL7 Version 3 Standard, Value Sets for AdministrativeGender and NullFlavor, attributed as follows: Male. 446151000124109 Female. 446141000124107 Female-to-Male (FTM)/Transgender Male/Trans Man. 407377005 Male-to-Female (MTF)/Transgender Female/Trans Woman. 407376001 Genderqueer, neither exclusively male nor female. 446131000124102 Additional gender category or other, please specify. nullFlavor OTH Choose not to disclose. nullFlavor ASKU Adopted at 45 CFR 170.207(o)(2)	A. Taylor	ONC	10/09/2020 - 23:18