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 |
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| USCDI V5 | Orders | Provider-authored request for the delivery of patient care services. |
Procedure Order | Provider-authored request for the performance of a diagnostic or therapeutic intervention. | Joel Andress | Centers for Medicare and Medicaid Services (CMS) Center for Clinical Standards and Quality (CCSQ) | ||
| USCDI V5 | Orders | Provider-authored request for the delivery of patient care services. |
Clinical Test Order | Provider-authored request for the performance of a non-laboratory or non-imaging test. | Joel Andress | Centers for Medicare and Medicaid Services (CMS) Center for Clinical Standards and Quality (CCSQ) | ||
| Draft USCDI V6 | 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 V6 | Clinical Notes | Narrative patient data relevant to the context identified by note types.
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Consultation Note |
Narrative summary of care provided in response to a request from a clinician for an opinion, advice, or service. Examples include but are not limited to dermatology, dentistry, and acupuncture. |
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| Draft USCDI V6 | Clinical Notes | Narrative patient data relevant to the context identified by note types.
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Discharge Summary Note |
Narrative 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 V6 | 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 V6 | Clinical Notes | Narrative patient data relevant to the context identified by note types.
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Procedure Note |
Narrative 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 V6 | Clinical Notes | Narrative patient data relevant to the context identified by note types.
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Progress Note |
Narrative 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 V6 | 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 V6 | 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 V6 | Immunizations | Record of vaccine administration. |
Immunizations |
Vaccine product administered, planned, or reported. |
Both standards are required:
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| Draft USCDI V6 | 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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| Draft USCDI V6 | Laboratory | Analysis of clinical specimens to obtain information about the health of a patient. |
Values/Results |
Documented findings of a tested specimen including structured and unstructured components. |
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| Draft USCDI V6 | Medications | Pharmacologic agents used in the diagnosis, cure, mitigation, treatment, or prevention of disease. |
Medications |
Pharmacologic agent used in the diagnosis, cure, mitigation, treatment, or prevention of disease. |
Optional:
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| Draft USCDI V6 | Patient Demographics/Information | Data used to categorize individuals for identification, records matching, and other purposes. |
First Name | |||||
| Draft USCDI V6 | Patient Demographics/Information | Data used to categorize individuals for identification, records matching, and other purposes. |
Last Name | |||||
| Draft USCDI V6 | Patient Demographics/Information | Data used to categorize individuals for identification, records matching, and other purposes. |
Previous Name | |||||
| Draft USCDI V6 | Patient Demographics/Information | Data used to categorize individuals for identification, records matching, and other purposes. |
Middle Name (including middle initial) | |||||
| Draft USCDI V6 | Patient Demographics/Information | Data used to categorize individuals for identification, records matching, and other purposes. |
Name Suffix |
Name component following family name that may be used to describe a person's position in a family. |
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| Draft USCDI V6 | Patient Demographics/Information | Data used to categorize individuals for identification, records matching, and other purposes. |
Sex |
Documentation of a specific instance of sex. |
Both values must be supported:
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