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 | 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. |
Pregnancy Status | Indicator that a patient is currently pregnant, not pregnant, or that their pregnancy status is unknown currently, as it relates to potential risks and exposures. |
Adam Bazer, MPD | Integrating the Healthcare Enterprise USA (IHE USA) | |||
| Draft USCDI V3 | Condition, diagnosis, or reason for seeking medical attention. |
Date of Resolution | Date of subsiding or termination of a symptom, problem, or condition. |
Steven Lane | Sutter Health | |||
| Draft USCDI V3 | Data used to categorize individuals for identification, records matching, and other purposes. |
Previous Name | ||||||
| Draft USCDI V3 | 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. |
Mental Function | Represents observations related to a patient's current level of cognitive functioning, including alertness, orientation, comprehension, concentration, and immediate memory for simple commands. |
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Michelle Dougherty | Submitted on behalf of the CMS Data Element Library (DEL) Health IT Workgroup | ||
| Draft USCDI V3 | Data used to categorize individuals for identification, records matching, and other purposes. |
Last Name | ||||||
| Draft USCDI V3 | Data used to categorize individuals for identification, records matching, and other purposes. |
First Name | ||||||
| Draft USCDI V3 | Pharmacologic agents used in the diagnosis, cure, mitigation, treatment, or prevention of disease. |
Medications |
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| 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 | Analysis of clinical specimens to obtain information about the health of a patient. |
Values/Results | Documented findings of the analysis of a tested specimen. Includes both structured and unstructured (narrative) components. |
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| Draft USCDI V3 | Narrative patient data relevant to the context identified by note types.
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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
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| Draft USCDI V3 | Analysis of clinical specimens to obtain information about the health of a patient. |
Tests | The name of the analysis of specimens derived from humans which provide information for the diagnosis, prevention, treatment of disease, or assessment of health. |
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| 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 | Narrative patient data relevant to the context identified by note types.
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Progress Note | Represents a patient’s interval status during a hospitalization, outpatient visit, treatment with a post-acute care provider, or other healthcare encounter. |
Logical Observation Identifiers Names and Codes (LOINC®) version 2.71
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| Draft USCDI V3 | Information related to interactions between healthcare providers and a patient. |
Encounter Location | Location of facility which delivered a person’s health care or related services |
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 Identifier | Al Taylor | ONC | ||||
| Draft USCDI V3 | Record of vaccine administration. |
Immunizations | Both standards are required
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| Draft USCDI V3 | Information about a person who participates or is expected to participate in the care of a patient. |
Care Team Member Location | Al Taylor | ONC | ||||
| Draft USCDI V3 | 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 Concerns | ||||||
| Draft USCDI V3 | Desired state to be achieved by a patient. |
Patient Goals | Desired outcomes of patient's care. |
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| Draft USCDI V3 | Narrative patient data relevant to the context identified by note types.
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History & Physical | Documents the current and past conditions and observations of the patient. |
Logical Observation Identifiers Names and Codes (LOINC®) version 2.71
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