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 |
|---|---|---|---|---|---|---|---|---|
| Level 0 | Health Status Assessments | Assessments of a health-related matter of interest, importance, or worry to a patient, patient’s authorized representative, or patient’s healthcare provider that could identify a need, problem, or condition. |
Self-care | This data element carries information on Self-care that is exchanged as observations. (Observations are characteristics that can be tested, measured, or observed and are communicated with a name-value pair structure). Self-care is a broad domain. Using the conceptual framework of the the International Classification of Function (ICF), it includes aspects such as eating, caring for teeth, putting clothes on, etc. Notes: • This data element is constrained to health data represented in data structures for observations. Observations should be represented using terminologies supporting this conceptual model, such as LOINC, which is designed for this purpose. Representing problems, goals, and other types of information related to functioning should use other data class structures as appropriate. • Examples of Self-care concepts can be found in the ICF browser at: https://apps.who.int/classifications/icfbrowser • Examples of demonstrated use of Self-care data can be found in the PACIO FHIR Functional Status Implementation Guide which supports exchange of observation data such as eating, oral hygiene, upper body dressing using assessments coded with LOINC. |
LOINC. LOINC is a freely available global standard that contains a well-developed model for representing variables, answer lists, and the collections that contain them.* Many clinical assessments, scales, and other observations related to functioning are present in LOINC, including all of the variables on the PAC assessments for SNFs, IRFs, LTCHs, and HHAs. Regenstrief operates a robust process for adding new content (including functioning assessment instruments) if key gaps are identified. *PMID: 22899966 |
Michelle Dougherty | Submitted on behalf of the CMS Data Element Library (DEL) Health IT Workgroup | |
| Level 0 | Pregnancy Information | Number Fetal Deaths This Delivery | The number of fetal deaths in this delivery. |
LOINC codes exist for each of the proposed data elements: 69461-2 - Mother's body weight --at delivery 68493-6 - Prenatal visits for this pregnancy # 69044-6 - Date first prenatal visit 57722-1 - Birth plurality of Pregnancy 73772-6 - Number of fetal deaths delivered 73773-4 - Number of infants in this delivery delivered alive |
Craig Newman | Altarum | ||
| Level 0 | Newborn's Delivery Information | Newborn hearing screen of ear - left | The hearing screening result for the leftear provides coded result values for pass, refer and not performed. There should be separate results for both the right Ear and left ear. |
54108-6 - Newborn hearing screen of Ear - left (including Preferred Answer List LL618-0) |
Craig Newman | Altarum | ||
| Level 0 | Newborn's Delivery Information | Apgar Score | APGAR score post-birth including scores at 1, 5 and 10 minutes. |
LOINC codes exist for each of the proposed data elements: 11884-4 - Gestational age Estimated 73766-8 - Place where birth occurred [US Standard Certificate of Live Birth] 64710-7 - Was your pregnancy a live birth, stillbirth, miscarriage, abortion, or ectopic pregnancy [PhenX] 8339-4 - Birth weight Measured 8305-5 - Body height --post partum 9272-6 - 1 minute Apgar Score 9274-2 - 5 minute Apgar Score 9271-8 - 10 minute Apgar Score |
Craig Newman | Altarum | ||
| Level 0 | Special Alerts for Care Handoffs | Medications RxNorm, SNOMED | Important drug-drug interactions |
ICD 10, SNOMED, LOINC, RxNorm |
Holly Miller, MD | MedAllies | ||
| Level 0 | Procedures | Activity performed for or on a patient as part of the provision of care. |
Procedure Treatment Intent | The purpose of a treatment, or the desired effect or outcome resulting from the treatment. For example, a treatment may be intended to completely or partially eradicate a disease process by disrupting its underlying physiological processes, resulting in improvement in health; or a treatment may have no expectation of eradication but rather may be intended simply to delay the onset of more severe symptoms; or may be intended to prolong life without any expectation of cure. NOTE: Treatment Intent has also been submitted under the Medications data class |
SNOMED CT codes for therapeutic intent (qualifier value) |
Andre Quina | MITRE | |
| Level 0 | Procedures | Activity performed for or on a patient as part of the provision of care. |
Location of Procedure | Healthcare service location within a facility where the procedure was performed. |
Location of Procedure: HSLOC (https://www.cdc.gov/nhsn/cdaportal/terminology/codesystem/hsloc.html) Transmission-based precautions: SNOMED CT |
Sheila Abner | CDC/NHSN | |
| Level 0 | Special Alerts for Care Handoffs | Special equipment needed LOINC | Oxygen |
ICD 10, SNOMED, LOINC, RxNorm |
Holly Miller, MD | MedAllies | ||
| Level 0 | Special Alerts for Care Handoffs | Internal devices LOINC | Stents |
ICD 10, SNOMED, LOINC, RxNorm |
Holly Miller, MD | MedAllies | ||
| Level 0 | Substance Use | Ethanol in blood | This data element includes the mass/volume of ethanol present in blood |
Most of the requested data elements are in LOINC, as per the codes below. We have requested the addition of the NIAAA Single-Item Screener and the diagnosis of Alcohol Use Disorder to LOINC. AUDIT-C : 72109-2 Ethanol in blood: 5640-8 Ever drink alcohol: 69721-9 Average daily alcohol intake: 74013-4 Alcohol binge episodes/month: 11286-2 Alcohol abuse or dependence: 74043-1 Alcohol help during pregnancy: 64718-0 |
Laura Kwako | National Institute on Alcohol Abuse and Alcoholism | ||
| Level 0 | Allergies and Intolerances | Harmful or undesired physiological responses associated with exposure to a substance. |
Food Allergy Intolerance | Common food substances and allergens that can cause harmful or undesirable physioloical responses when exposed to the substance or the substance is consumed. |
SNOMED CT with a value set created in VSAC (OID: 2.16.840.1.113762.1.4.1186.3) HL7 Cross Paradigm Specification: Allergy and Intolerance Substance Value Set(s) Definition: http://www.hl7.org/implement/standards/product_brief.cfm?product_id=482 was used to create the value set |
Becky Gradl | Academy of Nutrition and Dietetics | |
| Level 0 | Newborn's Delivery Information | Newborn hearing screen reason not performed of ear - right | The reason why the hearing screen was not done in right ear. |
73742-9 - Newborn hearing screen reason not performed of Ear - right (including Example Answer List LL2769-9) |
Craig Newman | Altarum | ||
| Level 0 | Newborn's Delivery Information | CCHD Newborn Screening Interpretation | The result of the screening of the preductal and postductal oxygen saturation measurements. |
LOINC 73700-7 - CCHD newborn screening interpretation |
Craig Newman | Altarum | ||
| Level 0 | Encounter Information | Information related to interactions between healthcare providers and a patient. |
Encounter Participant | Encounter Status: FHIR Encounter Status: http://hl7.org/fhir/ValueSet/encounter-status Classification of Encounter: V3 Value SetActEncounterCode: http://hl7.org/fhir/ValueSet/v3-ActEncounterCode Encounter Type: FHIR Encounter type: http://www.ama-assn.org/go/cpt Encounter participant type: FHIR Participant type: http://hl7.org/fhir/ValueSet/encounter-participant-type Reason for the encounter: FHIR Encounter Reason Codes: http://hl7.org/fhir/ValueSet/encounter-reason Hospital encounter discharge disposition: FHIR Discharge disposition: http://hl7.org/fhir/ValueSet/encounter-discharge-disposition Expected source(s) of payment for this encounter: FHIR Coverage Type and Self-Pay Codes: http://hl7.org/fhir/R4/valueset-coverage-type.html Encounter chief complaint: FHIR DiagnosisRole: http://hl7.org/fhir/R4/valueset-diagnosis-role.html |
Maria Michaels | CDC | ||
| Level 0 | Special Alerts for Care Handoffs | Patient behaviors with risk to self or others (reported or observed) ICD 10, SNOMED | Examples Include: |
ICD 10, SNOMED, LOINC, RxNorm |
Holly Miller, MD | MedAllies | ||
| Level 0 | Special Alerts for Care Handoffs | Scheduling (time specific interventions) LOINC | Indicate timing for scheduling essential testing, treatments, consults, procedures, and follow-up appointments. |
ICD 10, SNOMED, LOINC, RxNorm |
Holly Miller, MD | MedAllies | ||
| Level 0 | Encounter Information | Information related to interactions between healthcare providers and a patient. |
Encounter subject | Encounter Status: FHIR Encounter Status: http://hl7.org/fhir/ValueSet/encounter-status Classification of Encounter: V3 Value SetActEncounterCode: http://hl7.org/fhir/ValueSet/v3-ActEncounterCode Encounter Type: FHIR Encounter type: http://www.ama-assn.org/go/cpt Encounter participant type: FHIR Participant type: http://hl7.org/fhir/ValueSet/encounter-participant-type Reason for the encounter: FHIR Encounter Reason Codes: http://hl7.org/fhir/ValueSet/encounter-reason Hospital encounter discharge disposition: FHIR Discharge disposition: http://hl7.org/fhir/ValueSet/encounter-discharge-disposition Expected source(s) of payment for this encounter: FHIR Coverage Type and Self-Pay Codes: http://hl7.org/fhir/R4/valueset-coverage-type.html Encounter chief complaint: FHIR DiagnosisRole: http://hl7.org/fhir/R4/valueset-diagnosis-role.html |
Maria Michaels | CDC | ||
| Level 0 | Care Team Members | Information about a person who participates or is expected to participate in the care of a patient. |
Provider DEA Number | NPPES assigns a unique number to each registered provider DEA assigns a number to each requesting and qualified healthcare professional. |
Robert C Dieterle | On behalf of the Da Vinci Project | ||
| Level 0 | Care Team Members | Information about a person who participates or is expected to participate in the care of a patient. |
Provider NPI | NPPES assigns a unique number to each registered provider DEA assigns a number to each requesting and qualified healthcare professional. |
Robert C Dieterle | On behalf of the Da Vinci Project | ||
| Level 0 | Encounter Information | Information related to interactions between healthcare providers and a patient. |
Encounter status | Encounter Status: FHIR Encounter Status: http://hl7.org/fhir/ValueSet/encounter-status Classification of Encounter: V3 Value SetActEncounterCode: http://hl7.org/fhir/ValueSet/v3-ActEncounterCode Encounter Type: FHIR Encounter type: http://www.ama-assn.org/go/cpt Encounter participant type: FHIR Participant type: http://hl7.org/fhir/ValueSet/encounter-participant-type Reason for the encounter: FHIR Encounter Reason Codes: http://hl7.org/fhir/ValueSet/encounter-reason Hospital encounter discharge disposition: FHIR Discharge disposition: http://hl7.org/fhir/ValueSet/encounter-discharge-disposition Expected source(s) of payment for this encounter: FHIR Coverage Type and Self-Pay Codes: http://hl7.org/fhir/R4/valueset-coverage-type.html Encounter chief complaint: FHIR DiagnosisRole: http://hl7.org/fhir/R4/valueset-diagnosis-role.html |
Maria Michaels | CDC |