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 | Substance Use | Alcohol binge episodes per month | This data element comprises how many alcohol binge episodes an individual has per month |
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 | Medical Devices | Instrument, machine, appliance, implant, software, or similar device intended to be used for a medical purpose. |
UDI-Production Identifier Expiration Data or UDI-PI-Expiration Date | The date by which the label of a device states the device must or should be used. 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 0 | Medical Devices | Instrument, machine, appliance, implant, software, or similar device intended to be used for a medical purpose. |
UDI-Production Identifier-Distinct Identification Code or UDI-PI-DIC | The Distince Identification code (aka Donation Identification Number (DIN)) is applicable to devices that are also regulated as HCT/Ps and is a number that is assigned to each donation. This number/code is required to be part of the UDI when included on the label in order to provide the means to track the device back to its manufacturing source or otherwise allow the history of the device manufacturing, packaging, labeling, distribution and use to be determined. 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 0 | Immunizations | Record of vaccine administration. |
Patient Assertion of Vaccine Credentials | Whether or not the patient asserts they have verifiable vaccine credentials. |
HL7 FHIR: Vaccine Credential Patient Assertion Observation profile HL7 CDA: Vaccine Credential Patient Assertion Observation LOINC: 11370-4 "Immunization status - Reported" |
Nedra Garrett | CDC | |
| Level 0 | Explanation of Benefit | Health data as reflected in a patient's Explanation of Benefits (EOB) statements, typically derived from claims and other administrative data. |
Member Admission Date | The date corresponding with admission of the beneficiary to a facility and the onset of services. May precede the Statement From Date if this claim is for a beneficiary who has been continuously under care. |
NUBC, CPT, HCPCS, HIPPS, ICD-9, ICD-10, DRGs, NDC, POS, NCPDP codes, and X12 codes. |
Mark Roberts | Leavitt Partners | |
| Level 0 | Orders | 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. |
Portable Medical Orders for Life-Sustaining Treatments | Medical orders guide what medical interventions providers will perform for a patient. A portable medical order is a type of medical order. Portable medical orders are not authored by patients. They are authored by practitioners in the context of an electronic medical record system. The medical orders are provided to the patient in the form of a document so the orders can travel with the patient and be exchanged with other care providers who do not have access to the EMR where the orders originated. Medical orders regarding life-sustaining treatments are established by a practitioner regarding treatments that restore, sustain or prolong a patient’s life. These types of medical orders are intended to be consistent with the patient’s instructions and wishes. Orders to perform or not perform specific types of life-sustaining treatments are documented by physicians as medical orders within the EMR system used by the organization providing medical interventions or the practitioner’s EMR. When medical orders regarding life-sustaining treatment are produced in a portable format, they are portable medical orders for life-sustaining treatment. Currently, there is no national standard for the expected content in a portable medical order for life-sustaining treatments, as the content can vary by State and EMR system. All doctors, emergency medical professionals, and other healthcare professionals, must follow these medical orders as the patient moves from one location to another (hospital, care facility, home, etc.), unless a treating physician examines the patient, reviews the medical order for life-sustaining treatment, and through conversation with the patient detects the need for a replacement order or as a result of their own clinical judgement creates a replacement order. In an emergency situation, characterized by a life-threatening health crisis, if the patient is unable to speak for themselves, life-sustaining treatments and procedures that are legally required of medical and emergency personnel can be overridden by a valid portable medical order. Depending on the state, a portable medical order may go by any of the following names: • MOLST (Medical Orders for Life-Sustaining Treatment) • POLST (Physician Orders for Life-Sustaining Treatment) • MOST (Medical Orders for Scope of Treatment) • POST (Physician Orders for Scope of Treatment) • TPOPP (Transportable Physician Orders for Patient Preferences) • Out-of-hospital Do Not Resuscitate (DNR) Orders The above forms have historically been paper-based and siloed in EMRs that might contain a scanned image, or a clinical note that details the decisions documented in the portable medical order. Emergency and treating care teams do not have mechanisms for establishing that the copy they are provided is the most current version and that another, more recent portable medical order doesn’t exist that would contradict the order they are reviewing. These uploaded copies of the portable medical order for life-sustaining treatment are considered to be just as valid as the original paper medical order that was provided by a physician to the patient for whom it was written. The currently supported digital interchange format for portable medical orders is a pdf document, as there are not standard interoperable data elements. The pdf document can be represented as a C-CDA Unstructured Document or a FHIR DocumentReference to enable key administrative information to be processed. |
Portable Medical Orders for Life Sustaining Treatment The currently supported digital interchange format for portable POLST orders is a pdf document. The pdf document can be represented as a C-CDA Unstructured Document or a FHIR DocumentReference to enable key administrative information to be processed. There is no standard guidance about the expected content in a portable medical order for life sustaining treatments. The content varies by state and by EMR system. Portable Medical Orders for Life Sustaining treatment are a type of Medical Order. Data Element Code Definition Portable medical order form 93037-0 LOINC urn:oid:2.16.840.1.113883.6.1 Physician Order for Scope of Treatment which encompasses Physician Orders for Life-Sustaining Treatment (POLST) or Medical Orders for Life-Sustaining Treatment (MOLST). MOLST Observation In the context of a Patient Summary or Encounter Summary authored by a clinician or assembled by clinician’s EMR system, observations verifying a patient’s advance directive information and medical orders for life sustaining treatments using established standards for recording this type of information documented by providers. If a person has a medical order or physician order for life sustaining treatment (MOLST or POLST). This observation does not indicate what orders are included in the MOLST or POLST. It indicates if a MOLST or POLST exists. If a MOLST or POLST exists, the template includes a reference structure that can be used to point to the MOLST or POLST document. The vocabulary and structure needed to express this observation is provided in the HL7 CDA® R2 Implementation Guide: Personal Advance Care Plan (PACP) Document, Release 1 - US Realm STU Release 2 August 2020 Volume 2 – Templates. This observation can be used to document a patient authored statement about portable medical orders for life sustaining treatments or physician authored statements about there being portable medical orders for life sustaining treatments. Note that a physician’s own medical orders placed for life sustaining treatments are documented as medical orders placed within the physician’s own EMR. |
Matt Elrod on behalf of ADVault, Inc. | MaxMD | |
| Level 0 | Explanation of Benefit | Health data as reflected in a patient's Explanation of Benefits (EOB) statements, typically derived from claims and other administrative data. |
Member Discharge Date | Date the beneficiary was discharged from the facility, or died. Matches the Statement Thru Date. When there is a discharge date, the Patient Discharge Status Code indicates the final disposition of the patient after discharge. |
NUBC, CPT, HCPCS, HIPPS, ICD-9, ICD-10, DRGs, NDC, POS, NCPDP codes, and X12 codes. |
Mark Roberts | Leavitt Partners | |
| Level 0 | Adverse Events | Unintended effects associated with clinical interventions. |
Adverse Event Causality | Information on the possible cause of the event |
adverse events are mapped to MedDRA terminology |
Mitra Rocca | Food and Drug Administration | |
| Level 0 | Adverse Events | Unintended effects associated with clinical interventions. |
Medication Adverse Event | Type of the event itself in relation to the subject |
adverse events are mapped to MedDRA terminology |
Mitra Rocca | Food and Drug Administration | |
| Level 0 | Adverse Events | Unintended effects associated with clinical interventions. |
Adverse Event Suspect Entity | The suspected agent causing the adverse event |
adverse events are mapped to MedDRA terminology |
Mitra Rocca | Food and Drug Administration | |
| Level 0 | Explanation of Benefit | Health data as reflected in a patient's Explanation of Benefits (EOB) statements, typically derived from claims and other administrative data. |
Claim Other Payer Paid Amount | The reduction in the payment amount to reflect the current carrier as a secondary, teritary, etc, payer. May be multiple occurrences if the current carrier is a teritary, etc. carrier. |
NUBC, CPT, HCPCS, HIPPS, ICD-9, ICD-10, DRGs, NDC, POS, NCPDP codes, and X12 codes. |
Mark Roberts | Leavitt Partners | |
| Level 0 | Work Information | Usual Occupation | A self-reported, coded term for the type of work (paid or unpaid) done by a person for the longest amount of time during his or her life, not including voluntary work (done by choice for the benefit of others without compensation). |
Occupational Data for Health (Value Set - Occupation ONETSOC Detail (ODH)) https://phinvads.cdc.gov/vads/ViewValueSet.action?oid=2.16.840.1.114222.4.11.7901 Occupation CDC Census 2010 https://phinvads.cdc.gov/vads/ViewValueSet.action?oid=2.16.840.1.114222.4.11.7186 |
Nedra Garrett | CDC | ||
| Level 0 | Work Information | Usual Industry | A self-reported term that identifies the kind of business, i.e., primary business activity, in which a person has worked for the longest time while in their Usual Occupation. For a military position, this is the self-reported branch of service. If an appropriate term is not available (e.g., a new kind of business), then a text entry is used. | Occupational Data for Health (Value Set - Industry NAICS Detail (ODH)) https://phinvads.cdc.gov/vads/ViewValueSet.action?oid=2.16.840.1.114222.4.11.7900 Industry CDC Census 2010 http://hl7.org/fhir/us/odh/ValueSet-codesystem-industry-cdc-census-2010.html |
Nedra Garrett | CDC | ||
| Level 0 | Work Information | Job Work Schedule | A coded term for the typical arrangement of working hours for a job, as reported by the person. |
Value Set - Work Schedule (ODH) |
Nedra Garrett | CDC | ||
| Level 0 | Work Information | Job Work Classification | A coded term that characterizes the arrangement between the employer and the person in a job, such as 'paid work, self-employed' or 'voluntary work in disaster/emergency response', as reported by the person. |
PHVS_WorkClassification_ODH |
Nedra Garrett | CDC | ||
| Level 0 | Work Information | Job Supervisory Level or Pay Grade | A coded term that indicates the responsibilities of a person’s job for directing work and managing personnel, as reported by the person. Pay grade is used for a military position, since it distinguishes between officers and enlisted service members and conveys similar meaning across all branches of service. |
Occupational Data for Health (Value Set -Job Supervisory Level or Pay Grade (ODH)) |
Nedra Garrett | CDC | ||
| Level 0 | Explanation of Benefit | Health data as reflected in a patient's Explanation of Benefits (EOB) statements, typically derived from claims and other administrative data. |
Total Amount | Total amount for each category (i.e., submitted, eligible, etc.) |
NUBC, CPT, HCPCS, HIPPS, ICD-9, ICD-10, DRGs, NDC, POS, NCPDP codes, and X12 codes. |
Mark Roberts | Leavitt Partners | |
| Level 0 | Explanation of Benefit | Health data as reflected in a patient's Explanation of Benefits (EOB) statements, typically derived from claims and other administrative data. |
Claim Discount Amount | The amount of the discount. |
NUBC, CPT, HCPCS, HIPPS, ICD-9, ICD-10, DRGs, NDC, POS, NCPDP codes, and X12 codes. |
Mark Roberts | Leavitt Partners | |
| Level 0 | Medications | Pharmacologic agents used in the diagnosis, cure, mitigation, treatment, or prevention of disease. |
Medication Administration Status | A code specifying the status of the Administration of a drug. This would clearly identify the current status of the drug administration. At any time, some codes may be ambiguous, such as “in-progress”, in that it is not currently clear if the administration process moved forward. Other codes will provide definitive states of the administration. For instance, “completed” shows the administration was completed, while “entered-on-error” indicates the prescription process was halted and the administration did not move forward | In FHIR R4, https://www.hl7.org/fhir/medicationadministration-definitions.html#MedicationAdministration.status |
Scott Gordon | Food and Drug Administration | |
| Level 0 | Explanation of Benefit | Health data as reflected in a patient's Explanation of Benefits (EOB) statements, typically derived from claims and other administrative data. |
Member Paid Deductible | The portion of this service that the member must pay which is applied to the total period deductible. Deductibles are usually applied over a specific time period, such as per calendar year, per benefit period. |
NUBC, CPT, HCPCS, HIPPS, ICD-9, ICD-10, DRGs, NDC, POS, NCPDP codes, and X12 codes. |
Mark Roberts | Leavitt Partners |