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 V3 | Patient Demographics/Information | Data used to categorize individuals for identification, records matching, and other purposes. |
Occupation Industry |
Type of business that compensates for work or assigns work to an unpaid worker or volunteer. (e.g., U.S. Army, cement manufacturing, children and youth services) |
|
Nedra Garrett | CDC | |
| USCDI V3 | Patient Demographics/Information | Data used to categorize individuals for identification, records matching, and other purposes. |
Occupation |
Type of work of a person. (e.g., infantry, business analyst, social worker) |
|
Nedra Garrett | CDC | |
| USCDI V3 | Health Insurance Information | Data related to an individual’s insurance coverage for health care. |
Relationship to Subscriber |
Relationship of a patient to the primary insured person. |
Mark Roberts | Leavitt Partners | ||
| USCDI V3 | Health Insurance Information | Data related to an individual’s insurance coverage for health care. |
Coverage Status |
Presence or absence of health care insurance. |
Mark Roberts | Leavitt Partners | ||
| USCDI V3 | Patient Demographics/Information | Data used to categorize individuals for identification, records matching, and other purposes. |
Tribal Affiliation | Laura Conn | ||||
| USCDI V6 | Care Plans | Information that guides treatment of the patient and recommendations for future treatment. |
Health professional’s conclusions and working assumptions that will guide treatment of the patient. |
|||||
| USCDI V6 | Clinical Notes | Narrative patient data relevant to the context identified by note types.
|
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. |
|
||||
| USCDI V6 | Clinical Notes | Narrative patient data relevant to the context identified by note types.
|
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. |
|
||||
| USCDI V6 | Clinical Notes | Narrative patient data relevant to the context identified by note types.
|
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. |
|
|||
| USCDI V6 | Clinical Notes | Narrative patient data relevant to the context identified by note types.
|
Narrative summary of non-operative procedure. Examples include but are not limited to interventional cardiology, gastrointestinal endoscopy, and osteopathic manipulation. |
|
||||
| USCDI V6 | Clinical Notes | Narrative patient data relevant to the context identified by note types.
|
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. |
|
||||
| USCDI V6 | Goals and Preferences | Desired state to be achieved by a person or a person’s elections to guide care. |
Desired outcomes of patient’s care. Examples include but are not limited to blood pressure control, functional ability, and nutrition. |
|||||
| USCDI V6 | 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-related issue or worry. Examples include but are not limited to weight gain and cancer risk. |
|||||
| USCDI V6 | Immunizations | Record of vaccine administration. |
Vaccine product administered, planned, or reported. |
Both standards are required:
|
||||
| USCDI V6 | Laboratory | Analysis of clinical specimens to obtain information about the health of a patient. |
Analysis of specimens derived from humans which provide information for the diagnosis, prevention, treatment of disease, or assessment of health. |
|
||||
| USCDI V6 | Laboratory | Analysis of clinical specimens to obtain information about the health of a patient. |
Documented findings of a tested specimen including structured and unstructured components. |
|
||||
| USCDI V6 | Medications | Pharmacologic agents used in the diagnosis, cure, mitigation, treatment, or prevention of disease. |
Pharmacologic agent used in the diagnosis, cure, mitigation, treatment, or prevention of disease. |
Optional:
|
||||
| USCDI V6 | Patient Demographics/Information | Data used to categorize individuals for identification, records matching, and other purposes. |
||||||
| USCDI V6 | Patient Demographics/Information | Data used to categorize individuals for identification, records matching, and other purposes. |
||||||
| USCDI V6 | Patient Demographics/Information | Data used to categorize individuals for identification, records matching, and other purposes. |