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.

Draft USCDI V3

Activity performed for or on a patient as part of the provision of care.

Procedures
  • SNOMED International, Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT®) U.S. Edition, January 2022 Release
  • Current Procedural Terminology (CPT®) 2021, as maintained and distributed by the American Medical Association, for physician services and other health care services, and Healthcare Common Procedure Coding System (HCPCS), as maintained and distributed by HHS.
  • For technology primarily developed to record dental procedures: Code on Dental Procedures and Nomenclature (CDT), maintained and distributed by the American Dental Association, for dental services.

Optional:

  • International Classification of Diseases ICD-10-PCS 2021
Draft USCDI V3

Condition, diagnosis, or reason for seeking medical attention.

Problems
  • Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT®) U.S. Edition, January 2022 Release
  • International Classification of Diseases ICD-10-CM 2021
Draft USCDI V3

Information related to interactions between healthcare providers and a patient.

Encounter Diagnosis
  • SNOMED International, Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT®) U.S. Edition, January 2022 Release
  • International Classification of Diseases ICD-10-CM 2021
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.

  • SNOMED International, Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT®) U.S. Edition, January 2022 Release
  • Current Procedural Terminology (CPT®) 2021, as maintained and distributed by the American Medical Association, for physician services and other health care services
  • Healthcare Common Procedure Coding System (HCPCS) Level II, as maintained and distributed by HHS
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)

Draft USCDI V3

Data used to categorize individuals for identification, records matching, and other purposes.

Phone Number

Both standards are required

  • ITU-T E.123, Series E: Overall Network Operation, Telephone Service, Service Operation and Human Factors, International operation - General provisions concerning users: Notation for national and international telephone numbers, email addresses and web addresses, February 2001
  • ITU-T E.164, Series E: Overall Network Operation, Telephone Service, Service Operation and Human Factors, International operation - Numbering plan of the international telephone service, The international public telecommunication numbering plan, November 2010

Adopted at 45 CFR 170.207(q)(1)