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 | Clinical Notes | Narrative patient data relevant to the context identified by note types.
|
Progress Note | Represents a patient’s interval status during a hospitalization, outpatient visit, treatment with a post-acute care provider, or other healthcare encounter. |
Logical Observation Identifiers Names and Codes (LOINC®) version 2.70
|
|||
| USCDI V2 | Clinical Notes | Narrative patient data relevant to the context identified by note types.
|
Discharge Summary Note | A synopsis of a patient’s admission and course in a hospital or post-acute care setting. |
Logical Observation Identifiers Names and Codes (LOINC®) version 2.70
|
|||
| USCDI V2 | Health Concerns | Health related matter that is of interest, importance, or worry to someone who may be the patient, patient’s family or patient’s health care provider. |
Health Concerns | |||||
| Level 2 | Medical Devices | An instrument, machine, appliance, implant, software or other article intended to be used for a medical purpose. |
UDI-Production Identifier-Manufacturing Date or UDI-PI-Manufacturing Date | The date on which a device is manufactured. Taken from FDA Data Elements Reference Table - see https://www.fda.gov/media/88408/download |
Please see FDA UDI regulation and FDA Data Elements Reference Table - see https://www.fda.gov/media/88408/download. Please see FDA Formats by Accredited Issuing Agency that shows the structured of each of the parts of the UDI as a complete standard - https://www.fda.gov/media/96648/download UDI-DI and all AccessGUDID data elements are listed in NCI Thesaurus. See https://www.nlm.nih.gov/research/umls/sourcereleasedocs/current/NCI_FDA/index.html#:~:text=%20The%20NCI%20Thesaurus%20includes%20the%20following%20FDA,Global%20Unique%20Device%20Identification%20Database%20%28GUDID%29%20More%20 |
Terrie Reed | Symmetric Health Solutions | |
| Level 2 | Vital Signs | Physiologic measurements of a patient that indicate the status of the body’s life sustaining functions. |
BMI | LOINC |
Joel Andress | Centers for Medicare and Medicaid Services (CMS) Center for Clinical Standards and Quality (CCSQ) | ||
| Level 2 | Medications | Pharmacologic agents used in the diagnosis, cure, mitigation, treatment, or prevention of disease. |
Negation Rationale | Medications (including medications with dose): RxNORM Medication Route: SNOMED (i.e. OID: 2.16.840.1.113883.3.117.1.7.1.222) Negation Rationale (reason codes): SNOMED (i.e. OID: 2.16.840.1.113883.3.117.1.7.1.93) https://vsac.nlm.nih.gov/valueset/expansions?pr=ecqm Negation Rationale: https://www.hl7.org/fhir/valueset-reason-medication-not-given-codes.html , http://hl7.org/fhir/us/qicore/ValueSet-qicore-negation-reason.html |
Joel Andress | CMS | ||
| Level 2 | Nutrition and Diet | Oral Diet Type | The name or type of oral diet or diet restrictions that describe what can be consumed orally. For example “general healthful diet”, “consistent carbohydrate diet”, or “renal diet”. |
HL7 Version 2 – ODS – Dietary orders, supplements, and preferences (http://www.hl7.org/implement/standards/product_brief.cfm?product_id=185) In addition, many there are many nutrition-related terms in SNOMED CT. Many of these terms have been put in value sets in VSAC or through HL7 terminology. Here are some examples: |
Becky Gradl | Academy of Nutrition and Dietetics | ||
| Level 2 | Travel Information | Travel History Location | A location in a person’s travel history either as an address or as a coded location. |
1. SNOMED: 420008001 |Travel (event)| 2. Geographical location history (https://phinvads.cdc.gov/vads/ViewValueSet.action?oid=2.16.840.1.114222.4.11.3201) 3. ISO 3166 country codes (https://www.iso.org/iso-3166-country-codes.html) |
Craig Newman | Altarum | ||
| Level 2 | Travel Information | Travel History Dates | The dates spent in a location traveled to. |
§ SNOMED: 420008001 |Travel (event)| |
Craig Newman | Altarum | ||
| Level 2 | Immunizations | Record of vaccine administration. |
Vaccination Event Record Type | Indicates whether the vaccination event is based on a historical record (e.g., second hand knowledge of the vaccination event) or was administered at the facility submitting the data. |
LOINC:30952-6- Date and time of vaccination: https://loinc.org/30952-6/ PHINVAD Immunization Information Source |
Nedra Garrett | Centers for Disease Control and Prevention | |
| Level 2 | Immunizations | Record of vaccine administration. |
Immunization Status | Indicates the current status (i.e., completed, entered in error, not done) of the immunization event. |
Immunization Code: CVX: Vaccines Administered 2.16.840.1.113762.1.4.1010.6: https://vsac.nlm.nih.gov/valueset/2.16.840.1.113762.1.4.1010.6/expansion Immunization Code: National Drug Codes (NDC): http://www2a.cdc.gov/vaccines/iis/iisstandards/ndc_tableaccess.asp Immunization Status: FHIR Immunization Status Codes: http://hl7.org/fhir/ValueSet/immunization-status Immunization Administered Date: FHIR datatypes: dateTime, String: https://www.hl7.org/fhir/us/core/StructureDefinition-us-core-immunization-definitions.html#Immunization.occurrence[x] Reason Immunization Not Performed: FHIR Immunization Status Reason Codes: http://hl7.org/fhir/R4/valueset-immunization-status-reason.html |
Maria Michaels | CDC | |
| Level 2 | Diagnostic Imaging | Tests that result in visual images requiring interpretation by a credentialed professional. |
Imaging Reference | The technical details of the retrieval access path to indicate network services that can be used to access DICOM studies, series, or instances content and metadata (e.g., a DICOMweb server endpoint providing QIDO-RS, WADO-RS, or WADO-URI). |
LOINC/RSNA Radiology Playbook includes Diagnostic Imaging Procedure Codes and Descriptions. HL7 Standard for CDA® Release 2: Imaging Integration; Basic Imaging Reports in CDA and DICOM Release 1 references LOINC® Document Type Codes, SNOMED CT® Quantity Measurement Type Codes, as well as DICOM Code Systems. FHIR ImagingStudy references SNOMED CT Body Structures |
Brian Bialecki | American College of Radiology | |
| Level 2 | Biologically Derived Product | Material substance originating from a biological entity intended to be transplanted or infused into another (possibly the same) biological entity. |
Processing Facility | Provides details on the processing location of the product |
ISBT-128 Processing Facility Identification Number |
Barbee Whitaker | Food and Drug Administration (FDA) Center for Biologics Evaluation and Research (CBER) | |
| Level 2 | Biologically Derived Product | Material substance originating from a biological entity intended to be transplanted or infused into another (possibly the same) biological entity. |
Division | Provides details on aliquots or when a donation event involves more than one collection |
ISBT-128 Division Identifier |
Barbee Whitaker | Food and Drug Administration (FDA) Center for Biologics Evaluation and Research (CBER) | |
| Level 2 | Biologically Derived Product | Material substance originating from a biological entity intended to be transplanted or infused into another (possibly the same) biological entity. |
Source Identifier | Provides details on collections and pooled products such as donation identifier |
ISBT-128 Donation Identification Number |
Barbee Whitaker | Food and Drug Administration (FDA) Center for Biologics Evaluation and Research (CBER) | |
| Level 2 | Medical Devices | An instrument, machine, appliance, implant, software or other article intended to be used for a medical purpose. |
UDI-Production Identifier-Serial or UDI-PI-Serial | The number that allows for the identification of a device, indicating its position within a series.Taken from FDA Data Elements Reference Table - see https://www.fda.gov/media/88408/download |
Please see FDA UDI regulation and FDA Data Elements Reference Table - see https://www.fda.gov/media/88408/download. Please see FDA Formats by Accredited Issuing Agency that shows the structured of each of the parts of the UDI as a complete standard - https://www.fda.gov/media/96648/download UDI-DI and all AccessGUDID data elements are listed in NCI Thesaurus. See https://www.nlm.nih.gov/research/umls/sourcereleasedocs/current/NCI_FDA/index.html#:~:text=%20The%20NCI%20Thesaurus%20includes%20the%20following%20FDA,Global%20Unique%20Device%20Identification%20Database%20%28GUDID%29%20More%20 |
Terrie Reed | Symmetric Health Solutions | |
| Level 2 | Biologically Derived Product | Material substance originating from a biological entity intended to be transplanted or infused into another (possibly the same) biological entity. |
Unique Identifier | Provides a globally unique identifier code for an individual product. |
Medical Product of Human Origin Unique Identifier |
Barbee Whitaker | Food and Drug Administration (FDA) Center for Biologics Evaluation and Research (CBER) | |
| Level 2 | Biologically Derived Product | Material substance originating from a biological entity intended to be transplanted or infused into another (possibly the same) biological entity. |
Product Code | Provides a description of and supports traceability for a product |
ISBT-128 Product Description Code |
Barbee Whitaker | Food and Drug Administration (FDA) Center for Biologics Evaluation and Research (CBER) | |
| Level 2 | Diagnostic Imaging | Tests that result in visual images requiring interpretation by a credentialed professional. |
Accession Number | A unique identifier created by a departmental information system which identifies the Imaging Service Request. The Accession Number links the scheduled procedure, images, and their resulting diagnostic imaging report, created by the radiologist, back to the original order, supporting both clinical workflow and billing. The Accession Number may group one or more Requested Procedures. |
LOINC/RSNA Radiology Playbook includes Diagnostic Imaging Procedure Codes and Descriptions. |
Brian Bialecki | American College of Radiology | |
| Level 2 | Nutrition and Diet | Enteral Nutrition Type | Enteral Nutrition is the delivery of nutrients to a functional segment of the gastrointestinal tract distal to the oral cavity employing the use of a tube or catheter device to supply a liquid formula. This data element is for the type or brand name of the enteral formula. |
HL7 Version 2 – ODS – Dietary orders, supplements, and preferences (http://www.hl7.org/implement/standards/product_brief.cfm?product_id=185) In addition, many there are many nutrition-related terms in SNOMED CT. Many of these terms have been put in value sets in VSAC or through HL7 terminology. Here are some examples: |
Becky Gradl | Academy of Nutrition and Dietetics |