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 | Encounter Information | Information related to interactions between healthcare providers and a patient. |
Encounter Participant Time Period | 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 | 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 | 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 | Vital Signs | Physiologic measurements of a patient that indicate the status of the body’s life sustaining functions. |
Vital sign results: date and timestamps | LOINC codes for vitals—date and timestamps collected in standard format |
Joel Andress | Centers for Medicare and Medicaid Services (CMS) Center for Clinical Standards and Quality (CCSQ) | ||
| 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 | ||
| Level 0 | Encounter Information | Information related to interactions between healthcare providers and a patient. |
Location Associated Time Period | Encounter type/occurrence: SNOMED CT (example, value set OID: 2.16.840.1.113883.3.666.5.307) HCPCS (example, value set OID: 2.16.840.1.113883.3.464.1003.101.12.1087) CPT (example, value set OID: 2.16.840.1.113883.3.464.1003.101.12.1001) HL7 value set, encounter type: https://www.hl7.org/fhir/us/core/ValueSet-us-core-encounter-type.html Encounter Diagnosis/ Primary Diagnosis/Discharge Diagnosis: SNOMED CT ICD-10-CM Discharge Disposition: DischargeDisposition Code System http://terminology.hl7.org/CodeSystem/discharge-disposition Encounter Location: SNOMED HSLOC |
Joel Andress | Centers for Medicare and Medicaid Services (CMS) Center for Clinical Standards and Quality (CCSQ) | ||
| Level 0 | Newborn's Delivery Information | Gestational Age at Birth | LOINC codes are available for gestational age |
Kensaku Kawamoto, MD, PhD, MHS | University of Utah | |||
| 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 Acuity | Mike Schmidt | HiQ Services, LLC | |||
| 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. |
Social History Observation | In CCDA 2.1, the Social History Section and Observations recommend use of SNOMED CT codes that are members of the Social History Type Set Definition 2.16.840.1.113883.3.88.12.80.60 Value Set, but there are many other potential codes and code sets to represent values associated with Social Risk Factor assessment, observations, diagnoses and interventions. |
Al Taylor | ONC | ||
| 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 Acuity | Melissa Ayres | SSA | |||
| Level 0 | Medications | Pharmacologic agents used in the diagnosis, cure, mitigation, treatment, or prevention of disease. |
Medication experience | FHIR Resource: HL7 FHIR R4 MedicationStatement, aka R5 MedicationUsage Data element: MedicationStatement.status; MedicationUsage.takenAsOrdered Values in http://hl7.org/fhir/CodeSystem/medication-statement-status: {active | completed | entered-in-error | intended | stopped | on-hold | unknown | not-taken} These are defined in terms of taking; i.e., “active” in MedicationRequest means that the prescription can be filled, but in MedicationStatement, means that the patient is taking it. FHIR R5 target is to remove “status” and create “use,” with values { Taking | Taking as directed | Taking not as directed | Not Taking | Unknown (unable to obtain)} AVS/PVS system uses “I am taking this med {As written | Differently | Not taking | Unsure}” |
Maureen Layden, MD, MPH | United States Department of Veterans Affairs | ||
| Draft USCDI V3 | Data used to categorize individuals for identification, records matching, and other purposes. |
Current Address | Includes street name, number, city/town, state, and zip code. |
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| Draft USCDI V3 | Activity performed for or on a patient as part of the provision of care. |
Procedures |
Optional:
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| Draft USCDI V3 | Condition, diagnosis, or reason for seeking medical attention. |
Problems |
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| Draft USCDI V3 | Information related to interactions between healthcare providers and a patient. |
Encounter Diagnosis |
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Joel Andress | Centers for Medicare and Medicaid Services (CMS) Center for Clinical Standards and Quality (CCSQ) | |||
| Draft USCDI V3 | Activity performed for or on a patient as part of the provision of care. |
A service offered to a patient to address identified Social Determinants of Health concerns, problems, or diagnoses (e.g., Education about Meals on Wheels Program, Referral to transportation support programs). SDOH data relate to conditions in which people live, learn, work, and play and their effects on health risks and outcomes. |
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Mark Savage for Gravity Project | Gravity Project | |||
| Draft USCDI V3 | Data used to categorize individuals for identification, records matching, and other purposes. |
Preferred Language | Request for Comment (RFC) 5646, “Tags for Identifying Languages”, September 2009 Adopted at 45 CFR 170.207(g) |
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| Draft USCDI V3 | Data used to categorize individuals for identification, records matching, and other purposes. |
Phone Number | Both standards are required
Adopted at 45 CFR 170.207(q)(1) |
