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
Draft USCDI V4 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
Draft USCDI V4 Problems

Condition, diagnosis, or reason for seeking medical attention.

Date of Diagnosis

Date of first determination by a qualified professional of the presence of a problem or condition affecting a patient.

Steven Lane Sutter Health
Draft USCDI V4 Problems

Condition, diagnosis, or reason for seeking medical attention.

Date of Resolution

Date of subsiding or termination of a symptom, problem, or condition.

Steven Lane Sutter Health
Draft USCDI V4 Care Team Members

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

Care Team Member Name Al Taylor ONC
Draft USCDI V4 Care Team Members

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

Care Team Member Identifier

Sequence of characters used to uniquely refer to a member of the care team.

Examples include but are not limited to National Provider Identifier (NPI), and National Council of State Boards of Nursing Identifier (NCSBN ID).

Al Taylor ONC
Draft USCDI V4 Care Team Members

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

Care Team Member Location

Place where care is delivered by a care team member.

Examples include but are not limited to clinic address and location description.

Al Taylor ONC
Draft USCDI V4 Care Team Members

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

Care Team Member Role

Responsibility of an individual within the care team.

Examples include but are not limited to primary care physician and caregiver.

Al Taylor ONC
Draft USCDI V4 Care Team Members

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

Care Team Member Telecom

Phone or email contact information for a care team member.

  • 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 (incorporated by reference in § 170.299)
  • 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
Keith W. Boone Audacious Inquiry
Draft USCDI V4 Encounter Information

Information related to interactions between healthcare providers and a patient.

Encounter Location

Place where a patient’s care is delivered.

Joel Andress Centers for Medicare and Medicaid Services (CMS) Center for Clinical Standards and Quality (CCSQ)
Draft USCDI V4 Encounter Information

Information related to interactions between healthcare providers and a patient.

Encounter Identifier

Sequence of characters by which an encounter is known.

Maria Michaels CDC
Draft USCDI V4 Vital Signs

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

Average Blood Pressure

Mean value of two or more blood pressure readings in a specified time period.

Usage note: Must include both systolic and diastolic components of the mean and specify the relevant time period of measurements.

Both standards are required.

  • Logical Observation Identifiers Names and Codes (LOINC®) version 2.73
  • The Unified Code of Units for Measure, Revision 2.1


 

Matt Reid American Medical Association
Draft USCDI V4 Allergies and Intolerances

Harmful or undesired physiological responses associated with exposure to a substance.

Substance (Non-Medication)

Non-pharmacologic agent believed to cause a harmful or undesired physiologic response following exposure.

Examples include but are not limited to latex, eggs, pollen, and peanuts.

  • Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT®) U.S. Edition, September 2022 Release
John D'Amore Diameter Health
Draft USCDI V4 Procedures

Activity performed for or on a patient as part of the provision of care.

Time of Procedure

Time and/or date a procedure or other action is performed.

Sheila Abner CDC/NHSN
Draft USCDI V4 Medications

Pharmacologic agents used in the diagnosis, cure, mitigation, treatment, or prevention of disease.

Dose Unit of Measure

Unit of measure of a medication.

Examples include but are not limited to milligram (mg) and milliliter (mL).

  • The Unified Code for Units of Measure, Revision 2.1
Maria Michaels CDC
Draft USCDI V4 Medications

Pharmacologic agents used in the diagnosis, cure, mitigation, treatment, or prevention of disease.

Indication

Sign, symptom, or medical condition that is the reason for giving or taking a medication.

Maria Michaels CDC
Draft USCDI V4 Medications

Pharmacologic agents used in the diagnosis, cure, mitigation, treatment, or prevention of disease.

Fill Status

State of a medication with regards to dispensing or other activity.

Examples include but are not limited to dispensed, partially dispensed, and not dispensed.

Robert C Dieterle Submitted on behalf of the Da Vinci Project
Draft USCDI V4 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.

Mental/Cognitive Status

Assessment or screening for the presence of a mental or behavioral problem.

Examples include but are not limited to alertness, orientation, comprehension, concentration, and immediate memory for simple commands.

  • Logical Observation Identifiers Names and Codes (LOINC®) version 2.73
Michelle Dougherty Submitted on behalf of the CMS Data Element Library (DEL) Health IT Workgroup
Draft USCDI V4 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.

Pregnancy Status

State or condition of being pregnant or intent to become pregnant.

Examples include but are not limited to pregnant, not pregnant, and unknown.

Adam Bazer, MPD Integrating the Healthcare Enterprise USA (IHE USA)
Draft USCDI V4 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.

SDOH Assessment

Screening questionnaire-based, structured evaluation for a Social Determinants of Health-related risk.

Examples include but are not limited to food, housing, and transportation security.

  • Logical Observation Identifiers Names and Codes (LOINC®) version 2.73
  • Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT®) U.S. Edition, September 2022 Release
Mark Savage for Gravity Project Gravity Project
Draft USCDI V4 Problems

Condition, diagnosis, or reason for seeking medical attention.

SDOH Problems/Health Concerns

Social Determinants of Health-related health concerns, conditions, or diagnoses.

Examples include but are not limited to homelessness, and food insecurity.

  • Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT®) U.S. Edition, September 2022 Release
  • International Classification of Diseases ICD-10-CM 2022
Mark Savage for Gravity Project Gravity Project