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 |
|---|---|---|---|---|---|---|---|---|
| Draft USCDI V7 | Provider-authored request for the delivery of patient care services. Usage notes: Orders convey a provider’s intent to have a service performed on or for a patient, or to give instructions on future care. |
Provider-authored request for end-of-life or life-sustaining care for a person who has a serious life-limiting medical condition. Usage note: These are meant to follow a person regardless of when and where such an order might be needed (e.g., hospital, care facility, community, home). There are variations in requirements and names for portable medical orders based on jurisdiction. Examples include but are not limited to POLST (Portable Medical Order for Life-Sustaining Treatment), MOLST (Medical Orders for Life-Sustaining Treatment), and out-of-hospital DNR (do-not-resuscitate). |
Grace Glennon on behalf of Joel Andress and CMS-CCSQ | On behalf of Centers for Medicare and Medicaid Services (CMS) Center for Clinical Standards and Quality (CCSQ) | ||||
| Draft USCDI V7 | Data used to categorize individuals for identification, records matching, and other purposes. |
Tribe or band with which an individual associates. |
Laura Conn | |||||
| Draft USCDI V7 | Analysis of clinical specimens to obtain information about the health of a patient. |
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 | |||
| Draft USCDI V7 | Analysis of clinical specimens to obtain information about the health of a patient. |
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 | ||||
| Draft USCDI V7 | 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. |
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 | |||
| Draft USCDI V7 | Narrative patient data relevant to the context identified by note types.
|
Narrative summary of a surgical procedure. Usage note: May include procedures performed, operative and anesthesia times, findings observed, fluids administered, specimens obtained, and complications identified. |
|
Leslie Kelly Hall | Engaging Patient Strategy | |||
| Draft USCDI V7 | Desired state to be achieved by a person or a person’s elections to guide care. |
Information about a patient or provider authored document indicating its location, content, type, and verification status. Usage note: May include structured or unstructured data, whether a person has one or more advance directive documents, the type of advance directive, the location of the document, and whether it has been verified. Such documents may be used should a person be unable to communicate their wishes, preferences, or priorities to their provider. Examples include but are not limited to an indication that a living will is on file, a reference to the location of durable medical power of attorney, and the validating provider. |
Rachel Eager | New York eHealth Collaborative | ||||
| Draft USCDI V7 | Information that guides treatment of the patient and recommendations for future treatment. |
Shared plan informed by members of a coordinated care team that details conditions, needs, and goals along with strategies for addressing them. Usage notes: Includes problems, health concerns, assessments, goals, and interventions from across care settings. Examples include but are not limited to clinical care plans, condition-specific care plans, coordinated care plan. |
Julia Skapik | NACHC | ||||
| Draft USCDI V7 | Analysis of clinical specimens to obtain information about the health of a patient. |
Information about a specimen, including the container, that is used to determine a laboratory’s criteria for acceptability. Usage note: This may include information about the contents of the container, the container, and the label. Examples include but are not limited to hemolyzed, clotted, container leaking, and missing patient name. |
|
Han Tran | College of American Pathologists (CAP) | |||
| Draft USCDI V7 | Analysis of clinical specimens to obtain information about the health of a patient. |
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. |
|
Nedra Y Garrett | CDC | |||
| Draft USCDI V7 | Analysis of clinical specimens to obtain information about the health of a patient. |
Unit of measurement to report quantitative results. |
|
Nedra Y Garrett | CDC | |||
| Draft USCDI V7 | 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. |
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. |
|
Laurie P. Whitsel | American Heart Association/Physical Activity Alliance | |||
| Draft USCDI V7 | Narrative patient data relevant to the context identified by note types.
|
Narrative summary of care delivered in an emergency department. |
|
Smitha Vellanky, on behalf of Joel Andress and Centers for Medicare and Medicaid Services (CMS) Center for Clinical Standards and Quality (CCSQ) | On behalf of Centers for Medicare and Medicaid Services (CMS) Center for Clinical Standards and Quality (CCSQ) | |||
| Draft USCDI V7 | Pharmacologic agents used in the diagnosis, cure, mitigation, treatment, or prevention of disease. |
Physiological administration path of a therapeutic agent into or onto a patient. Examples include but are not limited to oral, topical, and intravenous. |
|
Smitha Vellanky, on behalf of Joel Andress and Centers for Medicare and Medicaid Services (CMS) Center for Clinical Standards and Quality (CCSQ) | On behalf of Centers for Medicare and Medicaid Services (CMS) Center for Clinical Standards and Quality (CCSQ) | |||
| Draft USCDI V7 | Record of vaccine administration. |
Sequence of characters representing a specific quantity of manufactured material within a batch of a vaccine product. |
Sandi Mitchell | J P Systems, Inc. | ||||
| Draft USCDI V7 | Data used to categorize individuals for identification, records matching, and other purposes. |
Indication of whether a person needs language interpretation services. |
|
Scott Stare | CMS Office of Minority Health | |||
| Draft USCDI V7 | Provider-authored request for the delivery of patient care services. Usage notes: Orders convey a provider’s intent to have a service performed on or for a patient, or to give instructions on future care. |
Provider-authored request for the performance of a laboratory test. |
|
Joel Andress | Centers for Medicare and Medicaid Services (CMS) Center for Clinical Standards and Quality (CCSQ) | |||
| Draft USCDI V7 | Provider-authored request for the delivery of patient care services. Usage notes: Orders convey a provider’s intent to have a service performed on or for a patient, or to give instructions on future care. |
Provider-authored request for the dispensing of a therapeutic agent. |
|
Joel Andress | Centers for Medicare and Medicaid Services (CMS) Center for Clinical Standards and Quality (CCSQ) | |||
| Draft USCDI V7 | Provider-authored request for the delivery of patient care services. Usage notes: Orders convey a provider’s intent to have a service performed on or for a patient, or to give instructions on future care. |
Provider-authored request for the performance of a diagnostic imaging study. |
|
Joel Andress | Centers for Medicare and Medicaid Services (CMS) Center for Clinical Standards and Quality (CCSQ) | |||
| Draft USCDI V7 | Provider-authored request for the delivery of patient care services. Usage notes: Orders convey a provider’s intent to have a service performed on or for a patient, or to give instructions on future care. |
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) |