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 V4 | Encounter Information | Information related to interactions between healthcare providers and a patient. |
Encounter Time |
Date/times related to an encounter. Examples include but are not limited to 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 V4 | Encounter Information | Information related to interactions between healthcare providers and a patient. |
Encounter Disposition |
Place or setting to which the patient left a hospital or encounter. |
Joel Andress | Centers for Medicare and Medicaid Services (CMS) Center for Clinical Standards and Quality (CCSQ) | ||
| USCDI V4 | Encounter Information | Information related to interactions between healthcare providers and a patient. |
Encounter Diagnosis |
Coded diagnoses associated with an episode of care. |
|
Joel Andress | Centers for Medicare and Medicaid Services (CMS) Center for Clinical Standards and Quality (CCSQ) | |
| USCDI V4 | Medications | Pharmacologic agents used in the diagnosis, cure, mitigation, treatment, or prevention of disease. |
Dose |
Amount of a medication for each administration. |
Joel Andress | CMS | ||
| USCDI V4 | Problems | 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 | ||
| USCDI V4 | 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 V4 | 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 V4 | Care Team Members | Information about a person who participates or is expected to participate in the care of a patient. |
Care Team Member Identifier |
Sequence of characters used to uniquely refer to a member of the care team. Examples include but are not limited to National Provider Identifier (NPI), and National Council of State Boards of Nursing Identifier (NCSBN ID). |
Al Taylor | ONC | ||
| USCDI V4 | Care Team Members | Information about a person who participates or is expected to participate in the care of a patient. |
Care Team Member Location | Al Taylor | ONC | |||
| USCDI V4 | Care Team Members | Information about a person who participates or is expected to participate in the care of a patient. |
Care Team Member Role |
Responsibility of an individual within the care team. Examples include but are not limited to primary care physician and caregiver. |
Al Taylor | ONC | ||
| USCDI V4 | 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. |
|
Keith W. Boone | Audacious Inquiry | |
| USCDI V4 | Encounter Information | Information related to interactions between healthcare providers and a patient. |
Encounter Location |
Place where a patient’s care is delivered. |
Joel Andress | Centers for Medicare and Medicaid Services (CMS) Center for Clinical Standards and Quality (CCSQ) | ||
| USCDI V4 | Encounter Information | Information related to interactions between healthcare providers and a patient. |
Encounter Identifier |
Sequence of characters by which an encounter is known. |
Maria Michaels | CDC | ||
| USCDI V4 | Vital Signs | Physiologic measurements of a patient that indicate the status of the body’s life sustaining functions. |
Average Blood Pressure |
Arithmetic average of systolic and diastolic components of two of more blood pressure readings in a specified time period or according to a specified algorithm or protocol. Examples include but are not limited to 3-day morning and evening home monitoring, clinical encounter repeat average, and 24-hour ambulatory measurement. |
Both standards are required.
|
Matt Reid | American Medical Association | |
| USCDI V4 | Allergies and Intolerances | Harmful or undesired physiological responses associated with exposure to a substance. |
Substance (Non-Medication) |
Non-pharmacologic agent believed to cause a harmful or undesired physiologic response following exposure. Examples include but are not limited to latex, eggs, pollen, and peanuts. |
|
John D'Amore | Diameter Health | |
| USCDI V4 | Procedures | Activity performed for or on a patient as part of the provision of care. |
Performance Time |
Time and/or date a procedure is performed. Examples include but are not limited to vaccine or medication administration times, surgery start time, and time ultrasound performed. |
Sheila Abner | CDC/NHSN | ||
| USCDI V4 | Medications | Pharmacologic agents used in the diagnosis, cure, mitigation, treatment, or prevention of disease. |
Dose Unit of Measure |
Unit of measure of a medication. Examples include but are not limited to milligram (mg) and milliliter (mL). |
|
Maria Michaels | CDC | |
| USCDI V4 | Medications | Pharmacologic agents used in the diagnosis, cure, mitigation, treatment, or prevention of disease. |
Indication |
Sign, symptom, or medical condition that is the reason for giving or taking a medication. |
|
Maria Michaels | CDC | |
| USCDI V4 | Medications | Pharmacologic agents used in the diagnosis, cure, mitigation, treatment, or prevention of disease. |
Fill Status |
State of a medication with regards to dispensing or other activity. Examples include but are not limited to dispensed, partially dispensed, and not dispensed. |
Robert C Dieterle | Submitted on behalf of the Da Vinci Project | ||
| 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. |
Mental/Cognitive Status |
Assessment or screening for the presence of a mental or behavioral problem. Examples include but are not limited to alertness, orientation, comprehension, concentration, and immediate memory for simple commands. |
|
Michelle Dougherty | Submitted on behalf of the CMS Data Element Library (DEL) Health IT Workgroup |
