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 |
|---|---|---|---|---|---|---|---|---|
| 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 Name | Al Taylor | ONC | |||
| USCDI V3.1 | Vital Signs | Physiologic measurements of a patient that indicate the status of the body’s life sustaining functions. |
Diastolic Blood Pressure | Both standards are required
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| USCDI V3.1 | Goals | Desired state to be achieved by a patient. |
Patient Goals | Desired outcomes of patient's care. |
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| USCDI V3.1 | Vital Signs | Physiologic measurements of a patient that indicate the status of the body’s life sustaining functions. |
Systolic Blood Pressure | Both standards are required
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| 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. |
Pregnancy Status |
State or condition of being pregnant or intent to become pregnant. (e.g., pregnant, not pregnant, intent to become pregnant, unknown) |
Adam Bazer, MPD | Integrating the Healthcare Enterprise USA (IHE USA) | ||
| USCDI V3.1 | Health Insurance Information | Data related to an individual’s insurance coverage for health care. |
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. |
Middle Name (Including middle initial) | |||||
| USCDI V3.1 | Patient Demographics/Information | Data used to categorize individuals for identification, records matching, and other purposes. |
Occupation Industry |
Type of business that compensates for work or assigns work to an unpaid worker or volunteer. (e.g., U.S. Army, cement manufacturing, children and youth services) |
|
Nedra Garrett | CDC | |
| 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:
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| USCDI V3.1 | Clinical Notes | Narrative patient data relevant to the context identified by note types.
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History & Physical |
Summary of current and past conditions and observations used to inform an episode of care. (e.g. admission, surgery, or other procedure) |
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| 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) |
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| USCDI V3.1 | Problems | 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 | ||
| 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
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| USCDI V3.1 | Assessment and Plan of Treatment | Health professional’s conclusions and working assumptions that will guide treatment of the patient. |
SDOH Assessment |
Screening questionnaire-based, structured evaluation (e.g., PRAPARE, Hunger Vital Sign®, AHC-HRSN screening tool) for a Social Determinants of Health-related risk. (e.g., food insecurity, housing instability, or transportation insecurity) |
Optional:
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Mark Savage for Gravity Project | Gravity 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. |
Functional Status |
Assessment of a patient’s capabilities, or their risks of development or worsening of a condition or problem. (e.g., fall risk, pressure ulcer risk, alcohol use) |
|
Holly Miller, MD | MedAllies | |
| USCDI V3.1 | Encounter Information | Information related to interactions between healthcare providers and a patient. |
Encounter Time |
Date/times 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) | ||
| USCDI V3.1 | Patient Demographics/Information | Data used to categorize individuals for identification, records matching, and other purposes. |
Email Address |
Unique identifier of an individual's email account that is used to send and receive email messages. |
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| USCDI V3.1 | Procedures | Activity performed for or on a patient as part of the provision of care. |
SDOH Interventions |
Actions or services to address an identified Social Determinants of Health-related health concern, condition, or diagnosis (e.g., education about food pantry program, referral to non-emergency medical transportation program) |
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Mark Savage for Gravity Project | Gravity Project | |
| USCDI V3.1 | Health Insurance Information | Data related to an individual’s insurance coverage for health care. |
Coverage Status |
Presence or absence of health care insurance. |
Mark Roberts | Leavitt Partners | ||
| USCDI V3.1 | Patient Demographics/Information | Data used to categorize individuals for identification, records matching, and other purposes. |
Ethnicity | Both standards are required
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