USCDI Export for the Public

Documented findings of a tested specimen including structured and unstructured components.

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

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

• RxNorm® Full Monthly Release, January 2, 2024

Optional:

• National Drug Code (NDC), January 16, 2024

Name component following family name that may be used to describe a person's position in a family.

Documentation of a specific instance of sex and/or gender information.

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

Known or estimated year, month, and day of the patient's birth.

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)

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)

• IETF (Internet Engineering Task Force) Request for Comment (RFC) 5646, “Tags for Identifying Languages”, September 2009

Adopted at 45 CFR 170.207(g)(2)

Place where a person is located or may be contacted.

Usage note: If the address pattern is not supported in the standard, implementations should align as closely as possible and avoid truncating any values. 

• Project US@ Technical Specification for Patient Addresses, Final Version 1.0

Both standards are required

• ITU-T E.123, Series E: Overall Network Operation, Telephone Service, Service Operation and Human Factors, International operation - General provisions concerning users: Notation for national and international telephone numbers, email addresses and web addresses, February 2001
• ITU-T E.164, Series E: Overall Network Operation, Telephone Service, Service Operation and Human Factors, International operation - Numbering plan of the international telephone service, The international public telecommunication numbering plan, November 2010

Adopted at 45 CFR 170.207(q)(1)

Condition, diagnosis, or reason for seeking medical attention.

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

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

• Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT) U.S. Edition, September 2023 Release
• Current Procedural Terminology (CPT®) 2023, as maintained and distributed by the American Medical Association, for physician services and other healthcare services, and Healthcare Common Procedure Coding System (HCPCS), as maintained and distributed by HHS
• Code on Dental Procedures and Nomenclature (CDT), maintained and distributed by the American Dental Association

Optional:

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

Date and time of author action.

Organization associated with author.

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, September 2023 Release

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)