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 | Laboratory | Analysis of clinical specimens to obtain information about the health of a patient. |
Values/Results | Documented findings of the analysis of a tested specimen. Includes both structured and unstructured (narrative) components. |
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| USCDI V2 | Immunizations | Record of vaccine administration. |
Immunizations |
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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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| 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 | Patient Demographics/Information | Data used to categorize individuals for identification, records matching, and other purposes. |
Birth time | FHIR birthTime extension |
Kensaku Kawamoto, MD, PhD, MHS | University of Utah | ||
| 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 | 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 | 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. |
Nutrition Order | A clinician (provider)-authored request for a diet, formula feeding (enteral), or nutritional supplement. | Michelle Ashafa | Academy of Nutrition and Dietetics | ||
| Level 2 | 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. |
Referral Order | Provider-authored request to another provider, specialist, or organization for care services. Examples include referral orders to a wound specialist or podiatrist. | Grace Glennon, on behalf of NCQA | NCQA | ||
| 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 | Clinical Notes | Narrative patient data relevant to the context identified by note types.
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Referral note | Documentation sent to a consultant, for example, by a primary care provider, summarizing the patient’s clinical history and reason for consult. |
Swapna Abhyankar | Regenstrief Institute, LOINC Document Ontology Subcommittee | ||
| 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 | ||
| 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 | Patient Demographics/Information | Data used to categorize individuals for identification, records matching, and other purposes. |
Deceased Indicator | Indicates if the individual is deceased or not. | Sarah Gaunt | The Association of Public Health Laboratories (APHL) | ||
| Level 2 | 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. |
Medical Device Order | Provider-authored request for medical devices, such as for therapeutic footwear or walking aids. | Grace Glennon, on behalf of NCQA | NCQA | ||
| Level 2 | Adverse Events | Unintended effects associated with clinical interventions. |
Adverse Event Outcome | Outcome of the event – i.e. death, hospitalization, fever |
Sandi Mitchell | J P Systems, Inc. |