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 |
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| USCDI V2 | Clinical Notes | Narrative patient data relevant to the context identified by note types.
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Consultation Note |
Contains the response to request from a clinician for an opinion or advice from another clinician. |
Logical Observation Identifiers Names and Codes (LOINC®) version 2.70
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| USCDI V2 | Laboratory | Analysis of clinical specimens to obtain information about the health of a patient. |
Tests | The name of the 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 V2 | Medications | Pharmacologic agents used in the diagnosis, cure, mitigation, treatment, or prevention of disease. |
Medications |
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| Level 2 | Facility Information | Physical place of available services or resources. |
Facility Managing Organization Identifier | Various: FHIR DSTU2, 3 and 4, CDA Release 2.0, HL7 V2 PL Data Type |
Keith W. Boone | Audacious Inquiry | ||
| Level 2 | Nutrition and Diet | Oral Diet Type | The name or type of oral diet or diet restrictions that describe what can be consumed orally. For example “general healthful diet”, “consistent carbohydrate diet”, or “renal diet”. |
HL7 Version 2 – ODS – Dietary orders, supplements, and preferences (http://www.hl7.org/implement/standards/product_brief.cfm?product_id=185) In addition, many there are many nutrition-related terms in SNOMED CT. Many of these terms have been put in value sets in VSAC or through HL7 terminology. Here are some examples: |
Becky Gradl | Academy of Nutrition and Dietetics | ||
| Level 2 | Organization | Healthcare Services | Describe a specific healthcare service or category of services (such as counseling, imaging, or laboratory) offered by an organization at a designated location, which can be either physical or virtual. The service provider may include hospitals, clinics, pharmacies, or other specialized healthcare providers. |
In addition to LOINC and SNOMED CT, other relevant code systems for the Healthcare Service data element include: 1. NDC (National Drug Code): For identifying medications and drug services. These additional code systems further support the standardized representation of healthcare services. |
Mike Hamidi | Vulcan | ||
| Level 2 | Nutrition and Diet | Enteral Nutrition Type | Enteral Nutrition is the delivery of nutrients to a functional segment of the gastrointestinal tract distal to the oral cavity employing the use of a tube or catheter device to supply a liquid formula. This data element is for the type or brand name of the enteral formula. |
HL7 Version 2 – ODS – Dietary orders, supplements, and preferences (http://www.hl7.org/implement/standards/product_brief.cfm?product_id=185) In addition, many there are many nutrition-related terms in SNOMED CT. Many of these terms have been put in value sets in VSAC or through HL7 terminology. Here are some examples: |
Becky Gradl | Academy of Nutrition and Dietetics | ||
| Level 2 | Travel Information | Travel History Location | A location in a person’s travel history either as an address or as a coded location. |
1. SNOMED: 420008001 |Travel (event)| 2. Geographical location history (https://phinvads.cdc.gov/vads/ViewValueSet.action?oid=2.16.840.1.114222.4.11.3201) 3. ISO 3166 country codes (https://www.iso.org/iso-3166-country-codes.html) |
Craig Newman | Altarum | ||
| Level 2 | Travel Information | Travel History Dates | The dates spent in a location traveled to. |
§ SNOMED: 420008001 |Travel (event)| |
Craig Newman | Altarum | ||
| Level 2 | Immunizations | Record of vaccine administration. |
Vaccination Event Record Type | Indicates whether the vaccination event is based on a historical record (e.g., second hand knowledge of the vaccination event) or was administered at the facility submitting the data. |
Nedra Garrett | Centers for Disease Control and Prevention | ||
| Level 2 | Immunizations | Record of vaccine administration. |
Immunization Status | Indicates the current status (i.e., completed, entered in error, not done) of the immunization event. |
Maria Michaels | CDC | ||
| Level 2 | Health Insurance Information | Data related to an individual’s insurance coverage for healthcare. |
Plan Name | Name of the health plan benefit offering assigned to the Plan Identifier. | Mark Roberts | Leavitt Partners | ||
| Level 2 | Health Insurance Information | Data related to an individual’s insurance coverage for healthcare. |
Plan Identifier | Business concept used by a health plan to describe its benefit offerings. | Mark Roberts | Leavitt Partners | ||
| Level 2 | Medications | Pharmacologic agents used in the diagnosis, cure, mitigation, treatment, or prevention of disease. |
Medication Administration | A record of a patient actually consuming a medicine, or if it has otherwise been administered to them. https://www.hl7.org/fhir/medicationadministration.html | Shelly Spiro | Pharmacy HIT Collaborative | ||
| Level 2 | Medications | Pharmacologic agents used in the diagnosis, cure, mitigation, treatment, or prevention of disease. |
Medication Administration | A record of a patient actually consuming a medicine, or if it has otherwise been administered to them. https://www.hl7.org/fhir/medicationadministration.html | Joel Andress | CMS | ||
| Level 2 | Medications | Pharmacologic agents used in the diagnosis, cure, mitigation, treatment, or prevention of disease. |
Medication Dispense Quantity | The amount of medication dispensed or to be dispensed. |
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| Level 2 | Encounter Information | Information related to interactions between healthcare providers and a patient. |
Appointment | A booking of a healthcare event among patient(s), practitioner(s), related person(s) and/or device(s) for a specific date/time. This may result in one or more Encounter(s). | Philip Lieberman | Analog Informatics Corporation | ||
| Level 2 | Allergies and Intolerances | Harmful or undesired physiological responses associated with exposure to a substance. |
Reaction Severity | The clinical assessment of a specific allergic reaction when it occurs (e.g., mild, moderate, severe). | From SNOMED CT Implementation Guide for Allergy, Hypersensitivity and Intolerance: As a result of a request from HL7 to SNOMED International about the possibility of mapping some of the required HL7® FHIR® Value Sets to SNOMED CT, an analysis of the ability of SNOMED CT to accommodate those needs was performed by the SNOMED CT on FHIR Workgroup. The required value sets of the FHIR AllergyIntolerance resource were included in this analysis. AllergyIntolerance.Reaction.Severity It was assessed that there was a good match between the HL7 required value set and the SNOMED CT << 272141005 |Severities (qualifier value)| subhierarchy. |
Mr. Charles Gabrial | Federal Electronic Health Record Modernization (FEHRM) Office | |
| Level 2 | Patient Demographics/Information | Data used to categorize individuals for identification, records matching, and other purposes. |
Identifier | An identifier for the patient |
Sarah Gaunt | Lantana Consulting Group | ||
| Level 2 | Problems | Condition, diagnosis, or reason for seeking medical attention. |
Condition Status | Disease trend, also referred to as disease status, represents the clinician's overall judgment on the current trend of a condition, e.g., whether it is stable, worsening (progressing), or improving (responding). The judgment may be based a single type or multiple kinds of evidence, such as imaging data, physical examination, tumor measurements, laboratory data, etc. The condition trend can be reported multiple times during the course of a condition, each report representing the clinical judgement at that point in time. The element is important in assessing disease progression and determining the efficacy of treatments. |
Andre Quina | MITRE |