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 | 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 | ||
| 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 | ||
| 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 | |||
| 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 high, and normal. |
|
Riki Merrick | Association of Public Health Laboratories | |
| 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. Example includes but is not limited to accession number. |
Riki Merrick | Association of Public Health Laboratories | ||
| 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. |
|
Clem McDonald | National Library of Medicine | |
| USCDI V4 | Laboratory | Analysis of clinical specimens to obtain information about the health of a patient. |
Specimen Condition Acceptability |
Information regarding a specimen, including the container, that does not meet a laboratory’s criteria for acceptability. Examples include but are not limited to hemolyzed, clotted, container leaking, and missing patient name. Usage note: This may include information about the contents of the container, the container, and the label. |
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Han Tran | College of American Pathologists (CAP) | |
| USCDI V4 | Laboratory | Analysis of clinical specimens to obtain information about the health of a patient. |
Result Reference Range |
Upper and lower limit of quantitative 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. |
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Nedra Y Garrett | CDC | |
| 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 quantitative laboratory test results. |
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Nedra Y Garrett | CDC | |
| 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. |
Physical Activity |
Evaluation of a patient's current or usual exercise. Examples include but are not limited to frequency of muscle-strengthening physical activity, days per week with moderate to strenuous physical activity, and minutes per day of moderate to strenuous physical activity. |
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Laurie P. Whitsel | American Heart Association/Physical Activity Alliance | |
| Draft USCDI V5 | 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. |
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| Draft USCDI V5 | Clinical Notes | Narrative patient data relevant to the context identified by note types.
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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. |
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| Draft USCDI V5 | Clinical Notes | Narrative patient data relevant to the context identified by note types.
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Discharge Summary Note |
Summary 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. |
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| Draft USCDI V5 | Clinical Notes | Narrative patient data relevant to the context identified by note types.
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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. |
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| Draft USCDI V5 | Clinical Notes | Narrative patient data relevant to the context identified by note types.
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Procedure Note |
Summary of non-operative procedure. Examples include but are not limited to interventional cardiology, gastrointestinal endoscopy, and osteopathic manipulation. |
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| Draft USCDI V5 | Clinical Notes | Narrative patient data relevant to the context identified by note types.
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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. |
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| Draft USCDI V5 | 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. |
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| Draft USCDI V5 | 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. |
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| Draft USCDI V5 | Immunizations | Record of vaccine administration. |
Immunizations |
Vaccine product administered, planned, or reported. |
Both standards are required:
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| Draft USCDI V5 | 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. |
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