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 Goals

Desired state to be achieved by a patient.

SDOH Goals

Desired future states for an identified Social Determinants of Health-related health concern, condition, or diagnosis.

Examples include but are not limited to food security, transportation security, and ability to access health care.

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

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

SDOH Interventions

Actions or services to address an identified Social Determinants of Health-related health concern, condition, or diagnosis.

Examples include but are not limited to education about food pantry program, referral to non-emergency medical transportation program.

  • SNOMED International, Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT®) U.S. Edition, September 2022 Release
  • Current Procedural Terminology (CPT®) 2022, as maintained and distributed by the American Medical Association, for physician services and other health care services
  • Healthcare Common Procedure Coding System (HCPCS) Level II, as maintained and distributed by HHS
Mark Savage for Gravity Project Gravity Project
Draft USCDI V4 Goals

Desired state to be achieved by a patient.

Treatment Intervention Preference

Person's goals, preferences, and priorities for care and treatment in case that person is unable to make medical decisions because of a serious illness or injury.

Examples include but are not limited to preferences regarding cardiopulmonary resuscitation, endotracheal intubation, and tube feeding.

  • Logical Observation Identifiers Names and Codes (LOINC®) version 2.73
Matt Elrod on behalf of ADVault, Inc. ADVault, Inc.
Draft USCDI V4 Goals

Desired state to be achieved by a patient.

Care Experience Preference

Person's goals, preferences, and priorities for overall experiences during their care and treatment.

Examples include but are not limited to honoring religious beliefs, and conditions of the care environment.

  • Logical Observation Identifiers Names and Codes (LOINC®) version 2.73
Matt Elrod on behalf of ADVault, Inc. ADVault, Inc.
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.

Substance Use

Evaluation of a patient's reported use of drugs or other substances for non-medical purposes or in excess of a valid prescription.

Examples include but are not limited to substance use disorder score, and substance use knowledge assessment. 

  • Logical Observation Identifiers Names and Codes (LOINC®) version 2.73
Jessica Cotto National Institute on Drug Abuse
Draft USCDI V4 Health Insurance Information

Data related to an individual’s insurance coverage for health care.

Subscriber Identifier

Sequence of characters used to uniquely refer to the individual that selects insurance benefits.

Robert C Dieterle On behalf of the Da Vinci Project
Draft USCDI V4 Health Insurance Information

Data related to an individual’s insurance coverage for health care.

Payer Identifier

Sequence of characters used to uniquely refer to an insurance payer.

Robert C Dieterle On behalf of the Da Vinci Project
Draft USCDI V4 Health Insurance Information

Data related to an individual’s insurance coverage for health care.

Coverage Type

Categories of health care payers.

Examples include but are not limited to Medicare, Tricare, Commercial Preferred Provider Organization.

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

Data related to an individual’s insurance coverage for health care.

Group Identifier

Sequence of characters used to uniquely refer to a specific health insurance plan.

Robert C Dieterle On behalf of the Da Vinci Project
Draft USCDI V4 Laboratory

Analysis of clinical specimens to obtain information about the health of a patient.

Result Status

State or condition of a laboratory test.

Maria Michaels CDC
Draft USCDI V4 Clinical Tests

Non-imaging and non-laboratory tests performed that result in structured or unstructured findings specific to the patient to facilitate the diagnosis and management of conditions.

Clinical Test

Non-imaging or non-laboratory test.

  • Logical Observation Identifiers Names and Codes (LOINC®) version 2.73
Joel Andress Centers for Medicare and Medicaid Services (CMS) Center for Clinical Standards and Quality (CCSQ)
Draft USCDI V4 Diagnostic Imaging

Tests that result in visual images requiring interpretation by a credentialed professional.

Diagnostic Imaging Test

Tests that generate visual images and require interpretation by qualified professionals.

Examples include but are not limited to radiographic, photographic, and video images.

  • Logical Observation Identifiers Names and Codes (LOINC®) version 2.73
Swapna Abhyankar Regenstrief Institute, LOINC Document Ontology Subcommittee
Draft USCDI V4 Diagnostic Imaging

Tests that result in visual images requiring interpretation by a credentialed professional.

Diagnostic Imaging Report

Interpreted results of imaging tests.

Usage Note: Includes both structured and unstructured (narrative) components.

Swapna Abhyankar Regenstrief Institute, LOINC Document Ontology Subcommittee
Draft USCDI V4 Laboratory

Analysis of clinical specimens to obtain information about the health of a patient.

Specimen Source Site

Body location from where a specimen was obtained.

Examples include but are not limited to right internal jugular, left arm, and right eye.

  • Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT®) U.S. Edition, September 2022 Release
Nedra Garrett Centers for Disease Control and Prevention
Draft USCDI V4 Laboratory

Analysis of clinical specimens to obtain information about the health of a patient.

Specimen Type

Substance being sampled or tested.

Examples include but are not limited to nasopharyngeal swab, whole blood, serum, urine, and wound swab. 

  • SNOMED International, Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT®) U.S. Edition, September 2022 Release
Nedra Garrett Centers for Disease Control and Prevention
Draft USCDI V4 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)
Draft USCDI V4 Patient Demographics/Information

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

Relationship Type

Relationship of a person to a patient.

Examples include but are not limited to parent, next-of-kin, guardian, and custodian.

Draft USCDI V4 Patient Demographics/Information

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

Related Person's Name

Name of a person with a legal or familial relationship to a patient.

Nedra Garrett Centers for Disease Control and Prevention
Draft USCDI V4 Patient Demographics/Information

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

Date of Death

Known or estimated year, month, and day of the patient's death.

Jeff Lyall Cigna
Draft USCDI V4 Patient Demographics/Information

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.

  • Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT®) U.S. Edition, September 2022 Release
A. Taylor ONC