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 V2 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)
  • Logical Observation Identifiers Names and Codes (LOINC®) version 2.70
  • The Unified Code of Units for Measure (UCUM), Revision 2.1
USCDI V2 Procedures

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

Procedures
  • SNOMED International, Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT®) U.S. Edition, March 2021 Release
  • Current Procedural Terminology (CPT®) 2021, 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 ICD-10-PCS 2021
USCDI V2 Encounter Information

Information related to interactions between healthcare providers and a patient.

Encounter Disposition

Identifies the location or type of facility to where the patient left following a hospital or encounter episode.

Joel Andress Centers for Medicare and Medicaid Services (CMS) Center for Clinical Standards and Quality (CCSQ)
USCDI V2 Unique Device Identifier(s) for a Patient's Implantable Device(s)

Unique identifier(s) for a patient's implantable device(s).

Unique Device Identifier(s) for a patient's implantable device(s)
  • FDA Unique Device Identification System (UDI System)
Marti Velezis FDA/CDRH/Indira Konduri (FDA/CDRH/OPEQ/ORP/DRPIII)
USCDI V2 Encounter Information

Information related to interactions between healthcare providers and a patient.

Encounter Time

Represents a date/time related to an encounter (e.g., scheduled appointment time, check in time, start and stop times).

Joel Andress Centers for Medicare and Medicaid Services (CMS) Center for Clinical Standards and Quality (CCSQ)
USCDI V2 Clinical Tests

Non-imaging and non-laboratory tests performed that result in structured or unstructured findings specific to the patient to facilitate the diagnosis and management of conditions.

Clinical Test Result/Report

Interpreted results of clinical tests that may include study performed, reason performed, findings, and impressions. Includes both structured and unstructured (narrative) components.

Melissa Ayres SSA
USCDI V2 Smoking Status

Representing a patient’s smoking behavior.

Smoking Status

Representing a patient’s smoking behaviors.

  • SNOMED International, Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT®) U.S. Edition, March 2021 Release
USCDI V2 Vital Signs

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

Inhaled Oxygen Concentration
  • Logical Observation Identifiers Names and Codes (LOINC®) version 2.70
  • The Unified Code of Units for Measure (UCUM), Revision 2.1
USCDI V2 Encounter Information

Information related to interactions between healthcare providers and a patient.

Encounter Diagnosis
  • SNOMED International, Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT®) U.S. Edition, March 2021 Release
  • International Classification of Diseases ICD-10-CM 2021
Joel Andress Centers for Medicare and Medicaid Services (CMS) Center for Clinical Standards and Quality (CCSQ)
USCDI V2 Procedures

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

SDOH Interventions

A service offered to a patient to address identified Social Determinants of Health concerns, problems, or diagnoses (e.g., Education about Meals on Wheels Program, Referral to transportation support programs). SDOH data relate to conditions in which people live, learn, work, and play and their effects on health risks and outcomes.

  • SNOMED International, Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT®) U.S. Edition, March 2021 Release
  • Current Procedural Terminology (CPT®) 2021, as maintained and distributed by the American Medical Association, for physician services and other health care services
  • Healthcare Common Procedure Coding System (HCPCS) Level II, as maintained and distributed by HHS
Mark Savage for Gravity Project Gravity Project
USCDI V2 Vital Signs

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

BMI Percentile (2 - 20 years)
  • Logical Observation Identifiers Names and Codes (LOINC®) version 2.70
  • The Unified Code of Units for Measure (UCUM), Revision 2.1
USCDI V2 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 V2 Patient Demographics/Information

Data used to categorize individuals for identification, records matching, and other purposes.

Phone Number Type
USCDI V2 Goals

Desired state to be achieved by a patient.

SDOH Goals

Identifies a future desired condition or change in condition related to an SDOH risk in any domain and is established by the patient or provider. (e.g., Has adequate quality meals and snacks, Transportation security-able to access health and social needs). SDOH data relate to conditions in which people live, learn, work, and play and their effects on health risks and outcomes.

  • SNOMED International, Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT®) U.S. Edition, March 2021 Release
  • Logical Observation Identifiers Names and Codes (LOINC®) version 2.70
Mark Savage for Gravity Project Gravity Project
USCDI V2 Provenance

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

Author Time Stamp
USCDI V2 Problems

Condition, diagnosis, or reason for seeking medical attention.

SDOH Problems/Health Concerns

An identified Social Determinants of Health-related condition (e.g., Homelessness (finding), Lack of adequate food Z59.41, Transport too expensive (finding)). SDOH data relate to conditions in which people live, learn, work, and play and their effects on health risks and outcomes.

  • ​​​​SNOMED International, Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT®) U.S. Edition, March 2021 Release
  • International Classification of Diseases ICD-10-CM 2021
Mark Savage for Gravity Project Gravity Project
USCDI V2 Vital Signs

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

Body Height
  • Logical Observation Identifiers Names and Codes (LOINC®) version 2.70
  • The Unified Code of Units for Measure (UCUM), Revision 2.1
USCDI V2 Patient Demographics/Information

Data used to categorize individuals for identification, records matching, and other purposes.

Current Address

Includes street name, number, city/town, state, and zip code.

USCDI V2 Vital Signs

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

Weight-for-length Percentile (Birth - 36 Months)
  • Logical Observation Identifiers Names and Codes (LOINC®) version 2.70
  • The Unified Code of Units for Measure (UCUM), Revision 2.1
USCDI V2 Patient Demographics/Information

Data used to categorize individuals for identification, records matching, and other purposes.

Phone Number

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)