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 |
|---|---|---|---|---|---|---|---|---|
| USCDI V3.1 | Medications | Pharmacologic agents used in the diagnosis, cure, mitigation, treatment, or prevention of disease. |
Dose |
Amount of a medication for each administration. |
Joel Andress | CMS | ||
| USCDI V3.1 | Vital Signs | Physiologic measurements of a patient that indicate the status of the body’s life sustaining functions. |
Body Temperature | Both standards are required
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| USCDI V3.1 | Procedures | Activity performed for or on a patient as part of the provision of care. |
Reason for Referral |
Explanation or justification for a referral or consultation. |
Adam Bazer, MPD | Integrating the Healthcare Enterprise USA (IHE USA) | ||
| USCDI V3.1 | Provenance | The metadata, or extra information about data, regarding who created the data and when it was created. |
Author Organization |
Organization associated with author. |
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| USCDI V3.1 | Vital Signs | Physiologic measurements of a patient that indicate the status of the body’s life sustaining functions. |
Pulse Oximetry | Both standards are required
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| USCDI V3.1 | Patient Demographics/Information | Data used to categorize individuals for identification, records matching, and other purposes. |
Date of Birth |
Known or estimated year, month, and day of the patient's birth. |
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| USCDI V3.1 | Assessment and Plan of Treatment | Health professional’s conclusions and working assumptions that will guide treatment of the patient. |
SDOH Assessment |
Screening questionnaire-based, structured evaluation (e.g., PRAPARE, Hunger Vital Sign®, AHC-HRSN screening tool) for a Social Determinants of Health-related risk. (e.g., food insecurity, housing instability, or transportation insecurity) |
Optional:
|
Mark Savage for Gravity Project | Gravity Project | |
| USCDI V3.1 | Provenance | The metadata, or extra information about data, regarding who created the data and when it was created. |
Author Time Stamp |
Date and time of author action. |
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| USCDI V3.1 | Clinical Notes | Narrative patient data relevant to the context identified by note types.
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Procedure Note |
Synopsis of non-operative procedures. (e.g., interventional cardiology, gastrointestinal endoscopy, osteopathic manipulation) |
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| USCDI V3.1 | Allergies and Intolerances | Harmful or undesired physiological responses associated with exposure to a substance. |
Substance (Medication) |
Pharmacologic agent believed to cause a harmful or undesired physiologic response following exposure. |
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| USCDI V3.1 | 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. |
Disability Status |
Assessments of a patient’s physical, cognitive, intellectual, or psychiatric disabilities. (e.g., vision, hearing, memory, activities of daily living) |
|
Grace Cordovano | Enlightening Results | |
| USCDI V3.1 | Laboratory | Analysis of clinical specimens to obtain information about the health of a patient. |
Tests |
Analysis of specimens derived from humans which provide information for the diagnosis, prevention, treatment of disease, or assessment of health. |
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| USCDI V3.1 | Problems | Condition, diagnosis, or reason for seeking medical attention. |
SDOH Problems/Health Concerns |
Social Determinants of Health-related health concerns, conditions, or diagnoses. (e.g., homelessness, food insecurity) |
|
Mark Savage for Gravity Project | Gravity Project | |
| USCDI V3.1 | Procedures | Activity performed for or on a patient as part of the provision of care. |
Procedures |
Optional:
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| USCDI V3.1 | Patient Demographics/Information | Data used to categorize individuals for identification, records matching, and other purposes. |
Related Person's Relationship |
Relationship of a person to a patient. (e.g., parent, next-of-kin, guardian, custodian) |
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| USCDI V3.1 | Vital Signs | Physiologic measurements of a patient that indicate the status of the body’s life sustaining functions. |
BMI Percentile (2 - 20 years) | Both standards are required
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| USCDI V3.1 | Encounter Information | Information related to interactions between healthcare providers and a patient. |
Encounter Type |
Category of health care service. (e.g., office visit, telephone assessment, home visit) |
Joel Andress | Centers for Medicare and Medicaid Services (CMS) Center for Clinical Standards and Quality (CCSQ) | ||
| USCDI V3.1 | Patient Demographics/Information | Data used to categorize individuals for identification, records matching, and other purposes. |
Phone Number |
Numbers and symbols to contact an individual when using a phone. |
Both standards are required:
Adopted at 45 CFR 170.207(q)(1) |
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| USCDI V3.1 | 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 |
Health-related issue or worry. (e.g., weight gain, cancer risk) |
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| USCDI V3.1 | Patient Demographics/Information | Data used to categorize individuals for identification, records matching, and other purposes. |
Preferred Language |
Adopted at 45 CFR 170.207(g)(2) |