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
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

Information about a person who participates or is expected to participate in the care of a patient.

Care Team Member Role Al Taylor ONC
Draft USCDI V3

Physiologic measurements of a patient that indicate the status of the body’s life sustaining functions.

Body Height
  • Logical Observation Identifiers Names and Codes (LOINC®) version 2.71
  • The Unified Code of Units for Measure, Revision 2.1
Draft USCDI V3

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. 
Procedure Note

Encompasses non-operative procedures including interventional cardiology, gastrointestinal endoscopy, osteopathic manipulation, and other specialty’s procedures.

Logical Observation Identifiers Names and Codes (LOINC®) version 2.71

  • Procedure Note (LOINC® code 28570-0)
Draft USCDI V3

Physiologic measurements of a patient that indicate the status of the body’s life sustaining functions.

Diastolic Blood Pressure

Both standards are required.

  • Logical Observation Identifiers Names and Codes (LOINC®) version 2.71
  • The Unified Code of Units for Measure, Revision 2.1
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

Data related to an individual’s insurance coverage for health care.

Subscriber Identifier

The identifier assigned to the individual that selects benefits offered by an employer or healthcare insurer.

Robert C Dieterle On behalf of the Da Vinci Project
Draft USCDI V3

Information about a person who participates or is expected to participate in the care of a patient.

Care Team Member Identifier Al Taylor ONC
Draft USCDI V3

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

Email Address
Draft USCDI V3

Information related to interactions between healthcare providers and a patient.

Encounter Type Joel Andress Centers for Medicare and Medicaid Services (CMS) Center for Clinical Standards and Quality (CCSQ)
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)

Draft USCDI V3

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

Race

Both standards are required

  • The Office of Management and Budget Standards for Maintaining, Collecting, and Presenting Federal Data on Race and Ethnicity, Statistical Policy Directive No. 15, as revised, October 30, 1997
  • CDC Race and Ethnicity Code Set Version 1.0 (March 2000)

Adopted at 45 CFR 170.207(f)

Draft USCDI V3

Information related to interactions between healthcare providers and a patient.

Encounter Time

Represents a date/time related to an encounter (e.g., scheduled appointment time, check in time, start and stop times).

Joel Andress Centers for Medicare and Medicaid Services (CMS) Center for Clinical Standards and Quality (CCSQ)
Draft USCDI V3

Condition, diagnosis, or reason for seeking medical attention.

Date of Diagnosis

Date of first determination by a qualified professional of the presence of a problem or condition affecting a patient.

Steven Lane Sutter Health
Draft USCDI V3

Data related to an individual’s insurance coverage for health care.

Member Identifier

Identifies an individual covered by the benefits offered by an employer or healthcare insurer.

Robert C Dieterle On behalf of the Da Vinci Project
Draft USCDI V3

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. 
Discharge Summary Note

A synopsis of a patient’s admission and course in a hospital or post-acute care setting. Must contain admission and discharge dates and locations, discharge instructions, and reason(s) for hospitalization.

Logical Observation Identifiers Names and Codes (LOINC®) version 2.71

  • Discharge Summary (LOINC® code 18842-5)
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.

Reason for Referral

An explanation or justification for why this service is being requested or was provided.

Adam Bazer, MPD Integrating the Healthcare Enterprise USA (IHE USA)
Draft USCDI V3

Information about a person who participates or is expected to participate in the care of a patient.

Care Team Member Name Al Taylor ONC
Draft USCDI V3

Physiologic measurements of a patient that indicate the status of the body’s life sustaining functions.

Systolic Blood Pressure

Both standards are required.

  • Logical Observation Identifiers Names and Codes (LOINC®) version 2.71
  • The Unified Code of Units for Measure, Revision 2.1