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 V5 | Laboratory | Analysis of clinical specimens to obtain information about the health of a patient. |
Result Reference Range |
Upper and lower limit of quantitative 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 | |
| USCDI V5 | Laboratory | Analysis of clinical specimens to obtain information about the health of a patient. |
Result Unit of Measure |
Unit of measurement to report quantitative laboratory test results. |
|
Nedra Y Garrett | CDC | |
| USCDI V5 | 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. |
Physical Activity |
Evaluation of a patient's current or usual exercise. Examples include but are not limited to frequency of muscle-strengthening physical activity, days per week with moderate to strenuous physical activity, and minutes per day of moderate to strenuous physical activity. |
|
Laurie P. Whitsel | American Heart Association/Physical Activity Alliance | |
| USCDI V5 | Clinical Notes | Narrative patient data relevant to the context identified by note types.
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Emergency Department Note |
Narrative summary of care delivered in an emergency department. |
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Smitha Vellanky, on behalf of Joel Andress and Centers for Medicare and Medicaid Services (CMS) Center for Clinical Standards and Quality (CCSQ) | On behalf of Centers for Medicare and Medicaid Services (CMS) Center for Clinical Standards and Quality (CCSQ) | |
| USCDI V5 | Medications | Pharmacologic agents used in the diagnosis, cure, mitigation, treatment, or prevention of disease. |
Route of Administration |
Physiological administration path of a therapeutic agent into or onto a patient. Examples include but are not limited to oral, topical, and intravenous. |
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Smitha Vellanky, on behalf of Joel Andress and Centers for Medicare and Medicaid Services (CMS) Center for Clinical Standards and Quality (CCSQ) | On behalf of Centers for Medicare and Medicaid Services (CMS) Center for Clinical Standards and Quality (CCSQ) | |
| USCDI V5 | Immunizations | Record of vaccine administration. |
Lot Number |
Sequence of characters representing a specific quantity of manufactured material within a batch of a vaccine product. |
Sandi Mitchell | J P Systems, Inc. | ||
| USCDI V5 | Patient Demographics/Information | Data used to categorize individuals for identification, records matching, and other purposes. |
Interpreter Needed |
Indication of whether a person needs language interpretation services. |
|
Scott Stare | CMS Office of Minority Health | |
| USCDI V5 | Orders | Provider-authored request for the delivery of patient care services. Usage notes: Orders convey a provider’s intent to have a service performed on or for a patient, or to give instructions on future care. |
Laboratory Order |
Provider-authored request for the performance of a laboratory test. |
Joel Andress | Centers for Medicare and Medicaid Services (CMS) Center for Clinical Standards and Quality (CCSQ) | ||
| USCDI V5 | Orders | Provider-authored request for the delivery of patient care services. Usage notes: Orders convey a provider’s intent to have a service performed on or for a patient, or to give instructions on future care. |
Medication Order |
Provider-authored request for the dispensing of a therapeutic agent. |
Joel Andress | Centers for Medicare and Medicaid Services (CMS) Center for Clinical Standards and Quality (CCSQ) | ||
| USCDI V5 | Orders | Provider-authored request for the delivery of patient care services. Usage notes: Orders convey a provider’s intent to have a service performed on or for a patient, or to give instructions on future care. |
Diagnostic Imaging Order | Provider-authored request for the performance of a diagnostic imaging study. | Joel Andress | Centers for Medicare and Medicaid Services (CMS) Center for Clinical Standards and Quality (CCSQ) | ||
| USCDI V5 | Orders | Provider-authored request for the delivery of patient care services. Usage notes: Orders convey a provider’s intent to have a service performed on or for a patient, or to give instructions on future care. |
Procedure Order | Provider-authored request for the performance of a diagnostic or therapeutic intervention. | Joel Andress | Centers for Medicare and Medicaid Services (CMS) Center for Clinical Standards and Quality (CCSQ) | ||
| USCDI V5 | Orders | Provider-authored request for the delivery of patient care services. Usage notes: Orders convey a provider’s intent to have a service performed on or for a patient, or to give instructions on future care. |
Clinical Test Order | Provider-authored request for the performance of a non-laboratory or non-imaging test. | Joel Andress | Centers for Medicare and Medicaid Services (CMS) Center for Clinical Standards and Quality (CCSQ) | ||
| Draft USCDI V6 | 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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| Draft USCDI V6 | Narrative patient data relevant to the context identified by note types.
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Consultation Note |
Narrative summary of care provided in response to a request from a clinician for an opinion, advice, or service. Examples include but are not limited to dermatology, dentistry, and acupuncture. |
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| Draft USCDI V6 | Narrative patient data relevant to the context identified by note types.
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Discharge Summary Note |
Narrative summary 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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| Draft USCDI V6 | Narrative patient data relevant to the context identified by note types.
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History & Physical |
Narrative 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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| Draft USCDI V6 | Narrative patient data relevant to the context identified by note types.
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Procedure Note |
Narrative summary of non-operative procedure. Examples include but are not limited to interventional cardiology, gastrointestinal endoscopy, and osteopathic manipulation. |
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| Draft USCDI V6 | Narrative patient data relevant to the context identified by note types.
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Progress Note |
Narrative 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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| Draft USCDI V6 | 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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| Draft USCDI V6 | 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. |