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 | Provenance | The metadata, or extra information about data, regarding who created the data and when it was created. |
Custodian | The custodian is the organization that is in charge of maintaining and is entrusted with the care of the document. |
Sarah Gaunt | The Association of Public Health Laboratories (APHL) | ||
| Draft USCDI V3 | 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 V3 | Clinical Notes | Narrative patient data relevant to the context identified by note types.
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Consultation Note | Response to request from a clinician for an opinion, advice, or service from another clinician. |
Logical Observation Identifiers Names and Codes (LOINC®) version 2.71
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| Draft USCDI V3 | 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. Must contain admission and discharge dates and locations, discharge instructions, and reason(s) for hospitalization. |
Logical Observation Identifiers Names and Codes (LOINC®) version 2.71
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| Draft USCDI V3 | 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 2.71
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| Draft USCDI V3 | Clinical Notes | Narrative patient data relevant to the context identified by note types.
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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
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| Draft USCDI V3 | Clinical Notes | Narrative patient data relevant to the context identified by note types.
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Progress Note | Represents a patient’s interval status during a hospitalization, outpatient visit, treatment with a post-acute care provider, or other healthcare encounter. |
Logical Observation Identifiers Names and Codes (LOINC®) version 2.71
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| Draft USCDI V3 | Goals | Desired state to be achieved by a patient. |
Patient Goals | Desired outcomes of patient's care. |
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| Draft USCDI V3 | 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. |
Health Concerns | |||||
| Draft USCDI V3 | Immunizations | Record of vaccine administration. |
Immunizations | Both standards are required
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| Draft USCDI V3 | Laboratory | 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. |
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| Draft USCDI V3 | Laboratory | Analysis of clinical specimens to obtain information about the health of a patient. |
Values/Results | Documented findings of the analysis of a tested specimen. Includes both structured and unstructured (narrative) components. |
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| Draft USCDI V3 | Medications | Pharmacologic agents used in the diagnosis, cure, mitigation, treatment, or prevention of disease. |
Medications |
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| Draft USCDI V3 | Patient Demographics/Information | Data used to categorize individuals for identification, records matching, and other purposes. |
First Name | |||||
| Draft USCDI V3 | Patient Demographics/Information | Data used to categorize individuals for identification, records matching, and other purposes. |
Last Name | |||||
| Draft USCDI V3 | Patient Demographics/Information | Data used to categorize individuals for identification, records matching, and other purposes. |
Previous Name | |||||
| Draft USCDI V3 | Patient Demographics/Information | Data used to categorize individuals for identification, records matching, and other purposes. |
Middle Name (including middle initial) | |||||
| Draft USCDI V3 | Patient Demographics/Information | Data used to categorize individuals for identification, records matching, and other purposes. |
Suffix | |||||
| Draft USCDI V3 | 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) |
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| Draft USCDI V3 | Patient Demographics/Information | Data used to categorize individuals for identification, records matching, and other purposes. |
Date of Birth |