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 V2 | 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 V2 | Health related matter that is of interest, importance, or worry to someone who may be the patient, patient’s family or patient’s health care provider. |
Health Concerns | ||||||
| Draft USCDI V2 | 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 V2 | Narrative patient data relevant to the context identified by note types.
|
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 2.69
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| Draft USCDI V2 | 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 V2 | 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 V2 | Narrative patient data relevant to the context identified by note types.
|
History & Physical | Documents the current and past conditions and observations of the patient. |
Logical Observation Identifiers Names and Codes (LOINC®) version 2.69
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| Draft USCDI V2 | Narrative patient data relevant to the context identified by note types.
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Consultation Note |
Contains the response to request from a clinician for an opinion or advice from another clinician. |
Logical Observation Identifiers Names and Codes (LOINC®) version 2.69
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| Draft USCDI V2 | 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 V2 | 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 V2 | Information related to interactions between healthcare providers and a patient. |
Encounter Diagnosis |
|
Joel Andress | Centers for Medicare and Medicaid Services (CMS) Center for Clinical Standards and Quality (CCSQ) | |||
| Draft USCDI V2 | Narrative patient data relevant to the context identified by note types.
|
Discharge Summary Note | A synopsis of a patient’s admission and course in a hospital or post-acute care setting. |
Logical Observation Identifiers Names and Codes (LOINC®) version 2.69
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| Draft USCDI V2 | Desired state to be achieved by a patient. |
Patient Goals | Desired outcomes of patient's care. |
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| USCDI V2 | Vital Signs | Physiologic measurements of a patient that indicate the status of the body’s life sustaining functions. |
Respiratory Rate |
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| USCDI V2 | Patient Demographics/Information | Data used to categorize individuals for identification, records matching, and other purposes. |
Previous Address | Includes street name, number, city/town, state, and zip code. |
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| USCDI V2 | Patient Demographics/Information | Data used to categorize individuals for identification, records matching, and other purposes. |
Sex (Assigned at Birth) | Birth sex must be coded in accordance with HL7 Version 3 (V3) Standard, Value Sets for AdministrativeGender and NullFlavor attributed as follows:
Adopted at 45 CFR 170.207(n) |
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| USCDI V2 | Allergies and Intolerances | Harmful or undesired physiological responses associated with exposure to a substance. |
Substance (Drug Class) |
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| USCDI V2 | 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 V2 | Patient Demographics/Information | Data used to categorize individuals for identification, records matching, and other purposes. |
Last Name | |||||
| USCDI V2 | Patient Demographics/Information | Data used to categorize individuals for identification, records matching, and other purposes. |
Date of Birth |