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 V4 | Data related to an individual’s insurance coverage for healthcare. |
Presence or absence of health care insurance. |
Mark Roberts | Leavitt Partners | ||||
| Draft USCDI V4 | Data used to categorize individuals for identification, records matching, and other purposes. |
Tribe or band with which an individual associates. |
Laura Conn | |||||
| Draft USCDI V4 | Analysis of clinical specimens to obtain information about the health of a patient. |
Categorical assessment of a laboratory value, often in relation to a test's reference range. Examples include but are not limited to high, low, critical, and normal. |
Riki Merrick | Association of Public Health Laboratories | ||||
| Draft USCDI V4 | Analysis of clinical specimens to obtain information about the health of a patient. |
Sequence of characters assigned by a laboratory for an individual specimen. |
Riki Merrick | Association of Public Health Laboratories | ||||
| Draft USCDI V4 | 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. |
Evaluation of a patient's consumption of alcohol. Examples include but are not limited to history of alcohol use, alcohol use disorder identification test and alcohol intake assessment. |
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Clem McDonald | National Library of Medicine | |||
| Draft USCDI V4 | Analysis of clinical specimens to obtain information about the health of a patient. |
Indication whether a specimen was acceptable and reason for rejection if unacceptable. |
Han Tran | College of American Pathologists (CAP) | ||||
| Draft USCDI V4 | Analysis of clinical specimens to obtain information about the health of a patient. |
Upper and lower limit of test values expected for a designated population of individuals. Usage note: reference range values may differ by patient characteristics, laboratory test manufacturer, and laboratory test performer. |
Nedra Y Garrett | CDC | ||||
| Draft USCDI V4 | Analysis of clinical specimens to obtain information about the health of a patient. |
Unit of measurement to report laboratory test results so that they can be compared. Usage note: required when the test result value is numeric. |
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Nedra Y Garrett | CDC | |||
| USCDI V4 | Patient Summary and Plan | Information that guides treatment of the patient and recommendations for future treatment. |
Assessment and Plan of Treatment |
Health professional’s conclusions and working assumptions that will guide treatment of the patient. |
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| USCDI V4 | Clinical Notes | Narrative patient data relevant to the context identified by note types.
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Consultation Note |
Response to request from a clinician for an opinion, advice, or service from another clinician. Examples include but are not limited to dermatology, dentistry, and acupuncture. |
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| USCDI V4 | Clinical Notes | Narrative patient data relevant to the context identified by note types.
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Discharge Summary Note |
Synopsis of a patient’s admission and course in a hospital or post-acute care setting. Usage note: Must contain admission and discharge dates and locations, discharge instructions, and reason(s) for hospitalization. Examples include but are not limited to dermatology discharge summary, hematology discharge summary, and neurology discharge summary. |
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| USCDI V4 | 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. Examples include but are not limited to admission, surgery, and other procedure. |
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| USCDI V4 | Clinical Notes | Narrative patient data relevant to the context identified by note types.
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Procedure Note |
Synopsis of non-operative procedure. Examples include but are not limited to interventional cardiology, gastrointestinal endoscopy, and osteopathic manipulation. |
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| USCDI V4 | Clinical Notes | Narrative patient data relevant to the context identified by note types.
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Progress Note |
Summary of a patient’s interval status during an encounter. Examples include but are not limited to hospitalization, outpatient visit, and treatment with a post-acute care provider, or other healthcare encounter. |
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| USCDI V4 | Goals and Preferences | Desired state to be achieved by a person or a person’s elections to guide care. |
Patient Goals |
Desired outcomes of patient’s care. |
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| USCDI V4 | 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. Examples include but are not limited to weight gain and cancer risk. |
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| USCDI V4 | Immunizations | Record of vaccine administration. |
Immunizations |
Vaccine product administered, planned, or reported. |
Both standards are required:
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| USCDI V4 | Laboratory | Analysis of clinical specimens to obtain information about the health of a patient. |
Tests |
Analysis of specimens derived from humans which provide information for the diagnosis, prevention, treatment of disease, or assessment of health. |
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| USCDI V4 | Laboratory | Analysis of clinical specimens to obtain information about the health of a patient. |
Values/Results |
Documented findings of a tested specimen including structured and unstructured components. |
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| USCDI V4 | Medications | Pharmacologic agents used in the diagnosis, cure, mitigation, treatment, or prevention of disease. |
Medications |
Pharmacologic agent used in the diagnosis, cure, mitigation, treatment, or prevention of disease. |
Optional:
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