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 V4 Problems

Condition, diagnosis, or reason for seeking medical attention.

Problems

Condition, diagnosis, or reason for seeking medical attention.

  • Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT®) U.S. Edition, March 2023 Release
  • International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) 2023
USCDI V4 Procedures

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

Procedures

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

  • SNOMED International, Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT®) U.S. Edition, March 2023 Release
  • Current Procedural Terminology (CPT®) 2023, as maintained and distributed by the American Medical Association, for physician services and other health care services, and Healthcare Common Procedure Coding System (HCPCS), as maintained and distributed by HHS.
  • For technology primarily developed to record dental procedures: Code on Dental Procedures and Nomenclature (CDT), maintained and distributed by the American Dental Association, for dental services.

Optional:

  • International Classification of Diseases, Tenth Revision, Procedure Coding System (ICD-10-PCS) 2023
USCDI V4 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.

USCDI V4 Provenance

The metadata, or extra information about data, regarding who created the data and when it was created.

Author Organization

Organization associated with author.

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.

Smoking Status

Assessment of a patient’s smoking behaviors.

Examples include but are not limited to pack-years and current use.

  • Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT®) U.S. Edition, March 2023 Release
USCDI V4 Medical Devices

An instrument, machine, appliance, implant, software or other article intended to be used for a medical purpose.

Unique Device Identifier - Implantable

Numeric or alphanumeric code that uniquely identifies an implantable device.

Usage note: Contains a Device Identifier (DI) and one or more Production Identifiers (PI).

FDA Unique Device Identification System (UDI System)

Marti Velezis FDA/CDRH/Indira Konduri (FDA/CDRH/OPEQ/ORP/DRPIII)
USCDI V4 Vital Signs

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

Diastolic Blood Pressure

Both standards are required.

  • Logical Observation Identifiers Names and Codes (LOINC®) version 2.74
  • The Unified Code of Units for Measure, Revision 2.1
USCDI V4 Vital Signs

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

Systolic Blood Pressure

Both standards are required.

  • Logical Observation Identifiers Names and Codes (LOINC®) version 2.74
  • The Unified Code of Units for Measure, Revision 2.1
USCDI V4 Vital Signs

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

Body Height

Both standards are required

  • Logical Observation Identifiers Names and Codes (LOINC®) version 2.74
  • The Unified Code of Units for Measure, Revision 2.1
USCDI V4 Vital Signs

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

Body Weight

Both standards are required

  • Logical Observation Identifiers Names and Codes (LOINC®) version 2.74
  • The Unified Code of Units for Measure, Revision 2.1
USCDI V4 Vital Signs

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

Heart Rate

Both standards are required

  • Logical Observation Identifiers Names and Codes (LOINC®) version 2.74
  • The Unified Code of Units for Measure, Revision 2.1
USCDI V4 Vital Signs

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

Respiratory Rate

Both standards are required

  • Logical Observation Identifiers Names and Codes (LOINC®) version 2.74
  • The Unified Code of Units for Measure, Revision 2.1
USCDI V4 Vital Signs

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

Body Temperature

Both standards are required

  • Logical Observation Identifiers Names and Codes (LOINC®) version 2.74
  • The Unified Code of Units for Measure, Revision 2.1
USCDI V4 Vital Signs

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

Pulse Oximetry

Both standards are required

  • Logical Observation Identifiers Names and Codes (LOINC®) version 2.74
  • The Unified Code of Units for Measure, Revision 2.1
USCDI V4 Vital Signs

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

Inhaled Oxygen Concentration

Both standards are required

  • Logical Observation Identifiers Names and Codes (LOINC®) version 2.74
  • The Unified Code of Units for Measure, Revision 2.1
USCDI V4 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

  • Logical Observation Identifiers Names and Codes (LOINC®) version 2.74
  • The Unified Code of Units for Measure, Revision 2.1
USCDI V4 Vital Signs

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

Weight-for-length Percentile (Birth - 24 Months)

Both standards are required

  • Logical Observation Identifiers Names and Codes (LOINC®) version 2.74
  • The Unified Code of Units for Measure, Revision 2.1
USCDI V4 Vital Signs

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

Head Occipital-frontal Circumference Percentile (Birth - 36 Months)

Both standards are required

  • Logical Observation Identifiers Names and Codes (LOINC®) version 2.74
  • The Unified Code of Units for Measure, Revision 2.1
USCDI V4 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.

  • RxNorm® Full Monthly Release, July 3, 2023
USCDI V4 Allergies and Intolerances

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

Substance (Drug Class)

Pharmacologic category for an agent believed to cause a harmful or undesired physiologic response following exposure.

  • Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT®) U.S. Edition, March 2023 Release