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Classification Level Sort descending	Data Class	Data Class Description	Data Element	Data Element Description	Applicable Standards	Submitter Name	Submitter Organization	Submission Date
Level 0	Clinical Notes	Narrative patient data relevant to the context identified by note types. Usage note: Clinical Notes data elements are content exchange standard agnostic. They should not be interpreted or associated with the structured document templates that may share the same name.	Antepartum Summary Note	The Antepartum Summary Note defines the aggregation of significant events, diagnoses, and plans of care derived from the visits over the course of an antepartum episode. It is a summary of the most critical information antepartum care providers capture and share regarding the status of a patient’s pregnancy. It is represented in part by Estimated Due Dates and summaries of the various antepartum visits. The information is aggregated data from which the patient’s interactions with care providers are captured. It includes data such as the patient’s allergies, advance directives, care planning, and selected histories. The antepartum summary note includes information such as structured evaluation of risk (e.g., PRAPARE, homelessness, AHC-HRSN screening tool, etc.) for any maternal health SDOH data related to conditions in which people live, learn, work, and play and their effects on health risks and outcomes; plan of care including social support interventions including but not limited to access to care; education; income; food stability; housing; neighborhood characteristics; safety; transportation security; violence/abuse preventions, ETOH, Smoking, Substance use disorder assessment and treatment drug abuse prevention and treatment; living arrangement; Social support involvement baby father involvement; etc.	SNOMED CT 276986009 Antepartum LOINC: 57061-4 Antepartum flowsheet panel Narrative https://loinc.org/57061-4/ 57055-6 Antepartum summary note https://loinc.org/57055-6/ ICD9 CM Complications of Pregnancy, Childbirth and the Puerperium http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.111.11.1021 ICD10CM, SNOMEDCT Complications of Pregnancy, Childbirth and the Puerperium http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.111.12.1012 Pregnancy https://vsac.nlm.nih.gov/valueset/2.16.840.1.113883.3.526.3.378/expansion	Andrea Fourquet	IHE USA	04/30/2022 - 01:26
Level 0	Cancer Care		Mode of Diagnosis	The diagnosis specifies a patient’s concern/problem after a series of diagnostic tests and screening procedures by the healthcare provider. Beyond the encounter diagnosis (existing USCDI data element), the Encounter Information should include the mode of diagnosis. The key to cancer treatment is the type of tumor and the encounter data must include how the diagnosis was assessed as well as the critical features on pathology (including modern molecular tumor profiling).	ICD-10 : https://www.cms.gov/Medicare/Coding/ICD10 SNOMED CT: https://www.snomed.org/	Kevin Jung	University of California San Francisco Breast Care Center	09/30/2022 - 23:14
Level 0	Clinical Tests	Non-imaging and non-laboratory tests performed that result in structured or unstructured findings specific to the patient to facilitate the diagnosis and management of conditions.	Myelogram	Narrative clinical assessment of the Myelogram results.	Please see suggestions from attached Excel document	Melissa Ayres	SSA	09/30/2022 - 20:25
Level 0	Clinical Tests	Non-imaging and non-laboratory tests performed that result in structured or unstructured findings specific to the patient to facilitate the diagnosis and management of conditions.	EKG/ECG Tracing Image	Narrative interpretation of the EKG/ECG Tracing Image.	Please see suggestions from attached Excel document	Melissa Ayres	SSA	09/30/2022 - 20:25
Level 0	Clinical Notes	Narrative patient data relevant to the context identified by note types. Usage note: Clinical Notes data elements are content exchange standard agnostic. They should not be interpreted or associated with the structured document templates that may share the same name.	Postpartum Summary Note	The postpartum summary note supports the inclusion of any interval medical history since delivery, physical and pelvic examination information, review of newborn status, discussion of birth control options, depression and intimate partner violence screenings, immunization review, counseling regarding any future pregnancies, and any interventional education, screenings, tests and results including laboratory. The postpartum summary note includes information such as structured evaluation of risk (e.g., PRAPARE, homelessness, AHC-HRSN screening tool, etc.) for any maternal health SDOH data related to conditions in which people live, learn, work, and play and their effects on health risks and outcomes; plan of care including social support interventions including but not limited to access to care; education; income; food stability; housing; neighborhood characteristics; safety; transportation security; violence/abuse preventions, ETOH, Smoking, Substance use disorder assessment and treatment drug abuse prevention and treatment; living arrangement; Social support involvement baby father involvement; etc.	SNOMED CT 55410009 Maternal postpartum 86569001 Postpartum state LOINC: 57076-2 Postpartum hospitalization treatment Narrative https://loinc.org/57076-2/ 57083-8 Labor and Delivery record panel https://loinc.org/57083-8/ 92576-8 Maternal discharge summary - recommended IHE set https://loinc.org/92576-8/ ICD9 CM Complications of Pregnancy, Childbirth and the Puerperium http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.111.11.1021 ICD10CM, SNOMED CT Complications of Pregnancy, Childbirth and the Puerperium http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.111.12.1012 Pregnancy https://vsac.nlm.nih.gov/valueset/2.16.840.1.113883.3.526.3.378/expansion	Andrea Fourquet	IHE USA	04/30/2022 - 00:30
Level 0	Clinical Notes	Narrative patient data relevant to the context identified by note types. Usage note: Clinical Notes data elements are content exchange standard agnostic. They should not be interpreted or associated with the structured document templates that may share the same name.	Maternal Social Determinants of Health Note	The Maternal Social Determinants of Health Note supports the aggregation of significant events, social problems and related health concerns, and plans of care derived from the visits over the course of a maternal care episode. It is a summary of the most critical information maternal care providers capture and share regarding the status of a maternal patient's social issues. The information is aggregated data from which the patient’s interactions with healthcare and social services providers are captured. The Maternal Social Determinants of Health Note includes information such as structured evaluation of risk (e.g., PRAPARE, homelessness, AHC-HRSN screening tool, etc.) for any maternal health SDOH data related to conditions in which people live, learn, work, and play and their effects on health risks and outcomes; plan of care including social support interventions including but not limited to access to care; education; income; food stability; housing; neighborhood characteristics; safety; transportation security; violence/abuse preventions, ETOH, Smoking, Substance use disorder assessment and treatment drug abuse prevention and treatment; living arrangement; Social support involvement baby father involvement; etc.	SNOMED CT 183425000 Social care 61072005 Social factor 315042007 Social support 161152002 Social problem 310134006 Social services 406551008 Social assessment 405076007 Social support status 108329005 Social context finding LOINC 52234-2 Medical social services treatment plan, Assessment information Set 52218-5 Medical social services treatment plan, Referral information Set 29762-2 Social history Narrative 91642-9 Medical Outcomes Study Social Support Survey panel 91663-5 Social support index ICD10 Z60.9 Problem related to social environment, unspecified Z60.8 Other problems related to social environment ICD9 CM Complications of Pregnancy, Childbirth and the Puerperium ICD10CM, SNOMEDCT Complications of Pregnancy, Childbirth and the Puerperium Pregnancy SNOMED CT: https://www.snomed.org/ LOINC: https://loinc.org/ ICD10: https://www.icd10data.com/	Asha G Immanuelle	Center For Black Women's Wellness	04/29/2022 - 15:06
Level 0	Clinical Notes	Narrative patient data relevant to the context identified by note types. Usage note: Clinical Notes data elements are content exchange standard agnostic. They should not be interpreted or associated with the structured document templates that may share the same name.	Autopsy Report	An autopsy is a post-mortem medical examination that a forensic pathologist, coroner, or medical examiner performs on the body of a deceased person.	https://loinc.org/18743-5/	Grace Cordovano	Enlightening Results	07/13/2021 - 20:57
Level 0	Clinical Notes	Narrative patient data relevant to the context identified by note types. Usage note: Clinical Notes data elements are content exchange standard agnostic. They should not be interpreted or associated with the structured document templates that may share the same name.	Tumor Board Notes	This may be a interdisciplinary note or a specific note for tumor boards.	https://loinc.org/85231-9/	Leslie Kelly Hall	Engaging Patient Strategy	06/29/2021 - 15:54
Level 0	Special Alerts for Care Handoffs		Infections ICD 10, SNOMED	Infection precautions (COVID 19, MPV, C diff, MRSA, MDRO, etc.) Vaccination status especially unvaccinated or contraindicated	ICD 10, SNOMED, LOINC, RxNorm	Holly Miller, MD	MedAllies	09/22/2022 - 19:51
Level 0	Clinical Tests	Non-imaging and non-laboratory tests performed that result in structured or unstructured findings specific to the patient to facilitate the diagnosis and management of conditions.	Holter monitor	Narrative clinical assessment of the Holter monitor results.	Please see suggestions from attached Excel document	Melissa Ayres	SSA	09/30/2022 - 20:25
Level 0	Clinical Tests	Non-imaging and non-laboratory tests performed that result in structured or unstructured findings specific to the patient to facilitate the diagnosis and management of conditions.	Visual Fields	Narrative clinical assessment of the Visual Fields evaluation.	Please see suggestions from attached Excel document	Melissa Ayres	SSA	09/30/2022 - 20:25
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.	Health Literacy Status	Degree to which individuals have the ability to find, understand, and use information and services to inform health-related decisions and actions for themselves and others.	LOINC 95866-0, BRIEF health literacy screening tool [BRIEF]; LOINC LL3268-1 (for answers)	Nedra Y Garrett	CDC	09/29/2022 - 18:04
Level 0	Newborn's Delivery Information		Reason CCHD oxygen saturation screening not performed	The reason that CCHD screening for newborns was not performed on this patient.	LOINC 73698-3 - Reason CCHD oxygen saturation screening not performed (including Preferred Answer List LL2458-9)	Craig Newman	Altarum	09/29/2022 - 16:59
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	09/22/2022 - 19:51
Level 0	Special Alerts for Care Handoffs		Patient behaviors with risk to self or others (reported or observed) ICD 10, SNOMED	Examples Include: Wandering Z91.83 Falls Z91.81 Confusion F05 Aggressive behavior F02.81 Physical violence R45.6 Suicidal ideation R45.851	ICD 10, SNOMED, LOINC, RxNorm	Holly Miller, MD	MedAllies	09/22/2022 - 19:51
Level 0	Special Alerts for Care Handoffs		Safety risks ICD 10, SNOMED, LOINC	Risks to safety of individual and/or organization/staff Weight bearing limitations Victim of abuse with or without restraining order (domestic violence, financial abuse, etc.)	ICD 10, SNOMED, LOINC, RxNorm	Holly Miller, MD	MedAllies	09/22/2022 - 19:51
Level 0	Special Alerts for Care Handoffs		Conditions with substantial risk of complications ICD 10, SNOMED	Serious chronic mental illness Transplants Substance Use Disorder Incontinence Healed pressure injury Active pressure injury	ICD 10, SNOMED, LOINC, RxNorm	Holly Miller, MD	MedAllies	09/22/2022 - 19:51
Level 0	Special Alerts for Care Handoffs		Medications RxNorm, SNOMED	Important drug-drug interactions High risk medications e.g.: anticoagulants opiates sedatives electrolyte altering hypoglycemics antipsychotics Immunosuppressants Tricyclic antidepressants Complicated regimens e.g.: loading tapering sliding scale precise schedule Instructions for missed or late medications	ICD 10, SNOMED, LOINC, RxNorm	Holly Miller, MD	MedAllies	09/22/2022 - 19:51
Level 0	Clinical Tests	Non-imaging and non-laboratory tests performed that result in structured or unstructured findings specific to the patient to facilitate the diagnosis and management of conditions.	Endoscopy	Narrative clinical assessment of the Endoscopy results.	Please see suggestions from attached Excel document	Melissa Ayres	SSA	09/30/2022 - 20:25
Level 0	Clinical Notes	Narrative patient data relevant to the context identified by note types. Usage note: Clinical Notes data elements are content exchange standard agnostic. They should not be interpreted or associated with the structured document templates that may share the same name.	Colonoscopy	Narrative clinical assessment of the Colonoscopy results.	Please see suggestions from attached Excel document	Melissa Ayres	SSA	09/30/2022 - 20:25