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Classification Level Sort descending	Data Class	Data Class Description	Data Element	Data Element Description	Applicable Standards
USCDI V4	Clinical Notes	Narrative patient data relevant to the context identified by note types. 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.	Discharge Summary Note	Synopsis of a patient’s admission and course in a hospital or post-acute care setting. Usage note: Must contain admission and discharge dates and locations, discharge instructions, and reason(s) for hospitalization. Examples include but are not limited to dermatology discharge summary, hematology discharge summary, and neurology discharge summary.	Logical Observation Identifiers Names and Codes (LOINC®) version 2.74 At minimum: Discharge Summary (LOINC code 18842-5)
USCDI V4	Clinical Notes	Narrative patient data relevant to the context identified by note types. 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.	History & Physical	Summary of current and past conditions and observations used to inform an episode of care. Examples include but are not limited to admission, surgery, and other procedure.	Logical Observation Identifiers Names and Codes (LOINC®) version 2.74 At minimum: History and Physical Note (LOINC code 34117-2)
USCDI V4	Clinical Notes	Narrative patient data relevant to the context identified by note types. 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.	Procedure Note	Synopsis of non-operative procedure. Examples include but are not limited to interventional cardiology, gastrointestinal endoscopy, and osteopathic manipulation.	Logical Observation Identifiers Names and Codes (LOINC®) version 2.74 At minimum: Procedure Note (LOINC code 28570-0)
USCDI V4	Clinical Notes	Narrative patient data relevant to the context identified by note types. 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.	Progress Note	Summary of a patient’s interval status during an encounter. Examples include but are not limited to hospitalization, outpatient visit, and treatment with a post-acute care provider, or other healthcare encounter.	Logical Observation Identifiers Names and Codes (LOINC®) version 2.74 At minimum: Progress Note (LOINC code 11506-3)
USCDI V4	Goals and Preferences	Desired state to be achieved by a person or a person’s elections to guide care.	Patient Goals	Desired outcomes of patient’s care.
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.	Health Concerns	Health-related issue or worry. Examples include but are not limited to weight gain and cancer risk.
USCDI V4	Immunizations	Record of vaccine administration.	Immunizations	Vaccine product administered, planned, or reported.	Both standards are required: IIS: Current HL7 Standard Code Set, CVX – Vaccines Administered, updates through June 6, 2023 Vaccine National Drug Code (NDC) Directory – Vaccine NDC Linker Table, updates through June 7, 2023
USCDI V4	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.	Logical Observation Identifiers Names and Codes (LOINC®) version 2.74
USCDI V4	Laboratory	Analysis of clinical specimens to obtain information about the health of a patient.	Values/Results	Documented findings of a tested specimen including structured and unstructured components.	Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT®) U.S. Edition, March 2023 Release
USCDI V4	Medications	Pharmacologic agents used in the diagnosis, cure, mitigation, treatment, or prevention of disease.	Medications	Pharmacologic agent used in the diagnosis, cure, mitigation, treatment, or prevention of disease.	RxNorm® Full Monthly Release July 3, 2023 Optional: National Drug Code (NDC), July 20, 2023
USCDI V4	Patient Demographics/Information	Data used to categorize individuals for identification, records matching, and other purposes.	First Name
USCDI V4	Patient Demographics/Information	Data used to categorize individuals for identification, records matching, and other purposes.	Last Name
USCDI V4	Patient Demographics/Information	Data used to categorize individuals for identification, records matching, and other purposes.	Previous Name
USCDI V4	Patient Demographics/Information	Data used to categorize individuals for identification, records matching, and other purposes.	Middle Name (including middle initial)
USCDI V4	Patient Demographics/Information	Data used to categorize individuals for identification, records matching, and other purposes.	Name Suffix	Name component following family name that may be used to describe a person's position in a family.
USCDI V4	Patient Demographics/Information	Data used to categorize individuals for identification, records matching, and other purposes.	Sex	Documentation of a specific instance of sex.	Both values must be supported: SNOMED CT U.S. Edition: 248152002 (Female) SNOMED CT U.S. Edition: 248153007 (Male)
USCDI V4	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.
USCDI V4	Patient Demographics/Information	Data used to categorize individuals for identification, records matching, and other purposes.	Race		Both standards are required The Office of Management and Budget Standards for Maintaining, Collecting, and Presenting Federal Data on Race and Ethnicity, Statistical Policy Directive No. 15, as revised, October 30, 1997 CDC Race and Ethnicity Code Set Version 1.2 (July 2021)
USCDI V4	Patient Demographics/Information	Data used to categorize individuals for identification, records matching, and other purposes.	Ethnicity		Both standards are required The Office of Management and Budget Standards for Maintaining, Collecting, and Presenting Federal Data on Race and Ethnicity, Statistical Policy Directive No. 15, as revised, October 30, 1997 CDC Race and Ethnicity Code Set Version 1.2 (July 2021)
USCDI V4	Patient Demographics/Information	Data used to categorize individuals for identification, records matching, and other purposes.	Preferred Language		IETF (Internet Engineering Task Force) Request for Comment (RFC) 5646, “Tags for Identifying Languages”, September 2009 Adopted at 45 CFR 170.207(g)(2)