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 Patient Demographics/Information

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

Sexual Orientation

A person’s emotional, romantic, sexual, or affectional attraction to another person.

  • SNOMED International, Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT®) U.S. Edition, September 2022 Release
A. Taylor ONC
Draft USCDI V4 Health Insurance Information

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

Member Identifier

Sequence of characters used to uniquely refer to an individual with respect to their insurance.

Robert C Dieterle On behalf of the Da Vinci Project
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 Result/Report

Findings of clinical tests.

Melissa Ayres SSA
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.

Functional Status

Assessment of a patient’s capabilities, or their risks of development or worsening of a condition or problem.

Examples include but are not limited to fall risk, and pressure ulcer risk.

  • Logical Observation Identifiers Names and Codes (LOINC®) version 2.73
Holly Miller, MD MedAllies
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.

Disability Status

Assessments of a patient’s physical, cognitive, intellectual, or psychiatric disabilities.

Examples include but are not limited to vision, hearing, memory, and activities of daily living.

  • Logical Observation Identifiers Names and Codes (LOINC®) version 2.73
Grace Cordovano Enlightening Results
Draft USCDI V4 Medications

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

Medication Instructions

Directions for administering or taking a medication.Examples include but are not limited to prescription directions for taking a medication, and package instructions for over-the-counter medications.

Shelly Spiro Pharmacy HIT Collaborative
Draft USCDI V4 Patient Demographics/Information

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

Occupation Industry

Type of business that compensates for work or assigns work to an unpaid worker or volunteer.

Examples include but are not limited to U.S. Army, cement manufacturing, and children and youth services.

  • Occupational Data for Health, version 20201030
Nedra Garrett CDC
Draft USCDI V4 Patient Demographics/Information

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

Occupation

Type of work of a person.

Examples include but are not limited to infantry, business analyst, and social worker.

Occupational Data for Health, version 20201030

Nedra Garrett CDC
Draft USCDI V4 Medications

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

Medication Adherence

Medication is consumed according to instructions.

Examples include but are not limited to taking as directed, taking not as directed, and not taking.

Shelly Spiro Pharmacy HIT Collaborative
Draft USCDI V4 Health Insurance Information

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

Relationship to Subscriber

Relationship of a patient to the primary insured person.

Mark Roberts Leavitt Partners
Draft USCDI V4 Health Insurance Information

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

Coverage Status

Presence or absence of health care insurance.

Mark Roberts Leavitt Partners
Draft USCDI V4 Patient Demographics/Information

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

Tribal Affiliation

Tribe or band with which an individual associates.

Laura Conn
Draft USCDI V4 Laboratory

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

Result Interpretation

Categorical assessment of a laboratory value, often in relation to a test's reference range.

Examples include but are not limited to high, low, critical, and normal.

Riki Merrick Association of Public Health Laboratories
Draft USCDI V4 Laboratory

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

Specimen Identifier

Sequence of characters assigned by a laboratory for an individual specimen.

Riki Merrick Association of Public Health Laboratories
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.

Alcohol Use

Evaluation of a patient's consumption of alcohol.

Examples include but are not limited to history of alcohol use, alcohol use disorder identification test and alcohol intake assessment.

  • Logical Observation Identifiers Names and Codes (LOINC®) version 2.73
Clem McDonald National Library of Medicine
Draft USCDI V4 Laboratory

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

Specimen Condition and Disposition

Indication whether a specimen was acceptable and reason for rejection if unacceptable.

Han Tran College of American Pathologists (CAP)
Draft USCDI V4 Laboratory

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

Result Reference Range

Upper and lower limit of test values expected for a designated population of individuals.

Usage note: reference range values may differ by patient characteristics, laboratory test manufacturer, and laboratory test performer.

Nedra Y Garrett CDC
Draft USCDI V4 Laboratory

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

Result Unit of Measure

Unit of measurement to report laboratory test results so that they can be compared.

Usage note: required when the test result value is numeric.

  • The Unified Code of Units for Measure, Revision 2.1
Nedra Y Garrett CDC
USCDI V4 Patient Summary and Plan

Conclusions and working assumptions that will guide treatment of the patient, and recommendations for future treatment.

Assessment and Plan of Treatment

Health professional’s conclusions and working assumptions that will guide treatment of the patient.

USCDI V4 Clinical Notes

Narrative patient data relevant to the context identified by note types.

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  • 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. 
Consultation Note

Response to request from a clinician for an opinion, advice, or service from another clinician.

Examples include but are not limited to dermatology, dentistry, and acupuncture.

  • Logical Observation Identifiers Names and Codes (LOINC®) version 2.74
    • At minimum: Consult Note (LOINC  code 11488-4)