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 V2 | Vital Signs | Physiologic measurements of a patient that indicate the status of the body’s life sustaining functions. |
Inhaled Oxygen Concentration |
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| USCDI V2 | Diagnostic Imaging | Tests that result in visual images requiring interpretation by a credentialed professional. |
Diagnostic Imaging Report | Interpreted results of imaging test that includes the study performed, reason, findings, and impressions. Includes both structured and unstructured (narrative) components. |
Swapna Abhyankar | Regenstrief Institute, LOINC Document Ontology Subcommittee | ||
| USCDI V2 | Clinical Notes | Narrative patient data relevant to the context identified by note types.
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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 2.70
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| USCDI V2 | Procedures | Activity performed for or on a patient as part of the provision of care. |
SDOH Interventions |
A service offered to a patient to address identified Social Determinants of Health concerns, problems, or diagnoses (e.g., Education about Meals on Wheels Program, Referral to transportation support programs). SDOH data relate to conditions in which people live, learn, work, and play and their effects on health risks and outcomes. |
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Mark Savage for Gravity Project | Gravity Project | |
| USCDI V2 | Goals | Desired state to be achieved by a patient. |
SDOH Goals | Identifies a future desired condition or change in condition related to an SDOH risk in any domain and is established by the patient or provider. (e.g., Has adequate quality meals and snacks, Transportation security-able to access health and social needs). SDOH data relate to conditions in which people live, learn, work, and play and their effects on health risks and outcomes. |
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Mark Savage for Gravity Project | Gravity Project | |
| USCDI V2 | Problems | Condition, diagnosis, or reason for seeking medical attention. |
Problems |
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| USCDI V2 | Clinical Tests | Non-imaging and non-laboratory tests performed that result in structured or unstructured findings specific to the patient to facilitate the diagnosis and management of conditions. |
Clinical Test | The name of the non-imaging or non-laboratory test performed on a patient. |
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Joel Andress | Centers for Medicare and Medicaid Services (CMS) Center for Clinical Standards and Quality (CCSQ) | |
| USCDI V2 | Problems | Condition, diagnosis, or reason for seeking medical attention. |
SDOH Problems/Health Concerns |
An identified Social Determinants of Health-related condition (e.g., Homelessness (finding), Lack of adequate food Z59.41, Transport too expensive (finding)). SDOH data relate to conditions in which people live, learn, work, and play and their effects on health risks and outcomes. |
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Mark Savage for Gravity Project | Gravity Project | |
| USCDI V2 | Vital Signs | Physiologic measurements of a patient that indicate the status of the body’s life sustaining functions. |
BMI Percentile (2 - 20 years) |
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| USCDI V2 | Assessment and Plan of Treatment | Health professional’s conclusions and working assumptions that will guide treatment of the patient. |
SDOH Assessment |
Structured evaluation of risk (e.g., PRAPARE, Hunger Vital Sign, AHC-HRSN screening tool) for any Social Determinants of Health domain such as food, housing, or transportation security. SDOH data relate to conditions in which people live, learn, work, and play and their effects on health risks and outcomes. |
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Mark Savage for Gravity Project | Gravity Project | |
| USCDI V2 | Patient Demographics/Information | Data used to categorize individuals for identification, records matching, and other purposes. |
Phone Number | Both standards are required
Adopted at 45 CFR 170.207(q)(1) |
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| USCDI V2 | 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 V2 | Patient Demographics/Information | Data used to categorize individuals for identification, records matching, and other purposes. |
Preferred Language | Request for Comment (RFC) 5646, “Tags for Identifying Languages”, September 2009 Adopted at 45 CFR 170.207(g) |
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| USCDI V2 | Patient Demographics/Information | Data used to categorize individuals for identification, records matching, and other purposes. |
Race | Both standards are required
Adopted at 45 CFR 170.207(f) |
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| USCDI V2 | Patient Demographics/Information | Data used to categorize individuals for identification, records matching, and other purposes. |
Sexual Orientation | A person’s identification of their emotional, romantic, sexual, or affectional attraction to another person |
Sexual orientation must be coded in accordance with SNOMED CT® and HL7 Version 3 Standard, Value Sets for AdministrativeGender and NullFlavor, attributed as follows:
Adopted at 45 CFR 170.207(o)(1) |
A. Taylor | ONC | |
| USCDI V2 | Patient Demographics/Information | Data used to categorize individuals for identification, records matching, and other purposes. |
Gender Identity | A person’s internal sense of being a man, woman, both, or neither. |
Gender Identify must be coded in accordance with SNOMED CT® and HL7 Version 3 Standard, Value Sets for AdministrativeGender and NullFlavor, attributed as follows:
Adopted at 45 CFR 170.207(o)(2) |
A. Taylor | ONC | |
| USCDI V2 | Provenance | The metadata, or extra information about data, regarding who created the data and when it was created. |
Author Organization | Organization associated with author. |
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| USCDI V2 | Patient Demographics/Information | Data used to categorize individuals for identification, records matching, and other purposes. |
Ethnicity | Both standards are required
Adopted at 45 CFR 170.207(f) |
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| USCDI V2 | 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) |
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| USCDI V2 | Encounter Information | 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) |