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 | 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. |
|
Keith W. Boone | Audacious Inquiry | |
| 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) | ||
| 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 | ||
| USCDI V4 | Vital Signs | Physiologic measurements of a patient that indicate the status of the body’s life sustaining functions. |
Average Blood Pressure |
Arithmetic average of systolic and diastolic components of two of more blood pressure readings in a specified time period or according to a specified algorithm or protocol. Examples include but are not limited to 3-day morning and evening home monitoring, clinical encounter repeat average, and 24-hour ambulatory measurement. |
Both standards are required.
|
Matt Reid | American Medical Association | |
| 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. |
|
John D'Amore | Diameter Health | |
| USCDI V4 | Procedures | Activity performed for or on a patient as part of the provision of care. |
Performance Time |
Time and/or date a procedure is performed. Examples include but are not limited to vaccine or medication administration times, surgery start time, and time ultrasound performed. |
Sheila Abner | CDC/NHSN | ||
| 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). |
|
Maria Michaels | CDC | |
| 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 | |
| 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 | ||
| 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. |
|
Michelle Dougherty | Submitted on behalf of the CMS Data Element Library (DEL) Health IT Workgroup | |
| 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) | ||
| 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. |
|
Mark Savage for Gravity Project | Gravity Project | |
| 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. |
|
Mark Savage for Gravity Project | Gravity Project | |
| USCDI V4 | Goals and Preferences | Desired state to be achieved by a person or a person’s elections to guide care. |
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. |
|
Mark Savage for Gravity Project | Gravity Project | |
| 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 and referral to non-emergency medical transportation program. |
|
Mark Savage for Gravity Project | Gravity Project | |
| USCDI V4 | Goals and Preferences | Desired state to be achieved by a person or a person’s elections to guide care. |
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 thoughts on cardiopulmonary resuscitation, mental health treatment preferences, and thoughts on pain management. |
|
Matt Elrod on behalf of ADVault, Inc. | ADVault, Inc. | |
| USCDI V4 | Goals and Preferences | Desired state to be achieved by a person or a person’s elections to guide care. |
Care Experience Preference |
Person's goals, preferences, and priorities for overall experiences during their care and treatment. Examples include but are not limited to religious beliefs, dislikes and fears, and thoughts and feelings to be shared. |
|
Matt Elrod on behalf of ADVault, Inc. | ADVault, Inc. | |
| 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. |
|
Jessica Cotto | National Institute on Drug Abuse | |
| 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 | ||
| 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 |