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

Narrative patient data relevant to the context identified by note types.

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  • 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. 
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

  • Progress Note (LOINC® code 11506-3)
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

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.

  • Logical Observation Identifiers Names and Codes (LOINC®) version 2.70
USCDI V3.1 Patient Demographics/Information

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

Ethnicity

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 1.2 (July 2021)
USCDI V3.1 Health Insurance Information

Data related to an individual’s insurance coverage for healthcare.

Group Identifier

Sequence of characters used to uniquely refer to a specific health insurance plan.

Robert C Dieterle On behalf of the Da Vinci Project
USCDI V3.1 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 Concerns

Health-related issue or worry. (e.g., weight gain, cancer risk)

USCDI V3.1 Patient Demographics/Information

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 1.2 (July 2021)
USCDI V3.1 Problems

Condition, diagnosis, or reason for seeking medical attention.

SDOH Problems/Health Concerns

Social Determinants of Health-related health concerns, conditions, or diagnoses. (e.g., homelessness, food insecurity)

  • SNOMED International, Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT®) U.S. Edition, March 2022 Release
  • International Classification of Diseases ICD-10-CM 2022
Mark Savage for Gravity Project Gravity Project
USCDI V3.1 Health Insurance Information

Data related to an individual’s insurance coverage for healthcare.

Coverage Status

Presence or absence of health care insurance.

Mark Roberts Leavitt Partners
USCDI V3.1 Health Insurance Information

Data related to an individual’s insurance coverage for healthcare.

Subscriber Identifier

Sequence of characters used to uniquely refer to the individual that selects insurance benefits.

Robert C Dieterle On behalf of the Da Vinci Project
USCDI V3.1 Vital Signs

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

Heart Rate

Both standards are required

  • Logical Observation Identifiers Names and Codes (LOINC®) version 2.72
  • The Unified Code of Units for Measure, Revision 2.1
USCDI V3.1 Vital Signs

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

Head Occipital-frontal Circumference Percentile (Birth - 36 Months)

Both standards are required

  • Logical Observation Identifiers Names and Codes (LOINC®) version 2.72
  • The Unified Code of Units for Measure, Revision 2.1
USCDI V3.1 Clinical Notes

Narrative patient data relevant to the context identified by note types.

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  • 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

Synopsis of non-operative procedures.  (e.g., interventional cardiology, gastrointestinal endoscopy, osteopathic manipulation)

  • Logical Observation Identifiers Names and Codes (LOINC®) version 2.72
    • At minimum: Procedure Note (LOINC® code 28570-0)
USCDI V3.1 Vital Signs

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

Body Temperature

Both standards are required

  • Logical Observation Identifiers Names and Codes (LOINC®) version 2.72
  • The Unified Code of Units for Measure, Revision 2.1
USCDI V3.1 Health Insurance Information

Data related to an individual’s insurance coverage for healthcare.

Coverage Type

Category of health care payers. (e.g., Medicare, TRICARE, Commercial Managed Care - PPO)

Joel Andress Centers for Medicare and Medicaid Services (CMS) Center for Clinical Standards and Quality (CCSQ)
USCDI V3.1 Patient Demographics/Information

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

Sex

Documentation of a specific instance of sex.

Both values must be supported:

  • SNOMED CT U.S. Edition: 248152002 (Female)
  • SNOMED CT U.S. Edition: 248153007 (Male)
USCDI V3.1 Vital Signs

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

Respiratory Rate

Both standards are required

  • Logical Observation Identifiers Names and Codes (LOINC®) version 2.72
  • The Unified Code of Units for Measure, Revision 2.1
USCDI V3.1 Clinical Notes

Narrative patient data relevant to the context identified by note types.

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  • 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. 
History & Physical

Summary of current and past conditions and observations used to inform an episode of care. (e.g. admission, surgery, or other procedure)

  • Logical Observation Identifiers Names and Codes (LOINC®) version 2.72
    • At minimum: History and Physical Note (LOINC® code 34117-2)
USCDI V3.1 Care Team Members

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

Care Team Member Telecom

Phone or email contact information for a care team member

  • 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 (incorporated by reference in § 170.299)
  • 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
Keith W. Boone Audacious Inquiry
USCDI V3.1 Clinical Notes

Narrative patient data relevant to the context identified by note types.

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  • 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. 
Consultation Note

Response to request from a clinician for an opinion, advice, or service from another clinician.

  • Logical Observation Identifiers Names and Codes (LOINC®) version 2.72
    • At minimum: Consult Note (LOINC® code 11488-4)