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 V6 | 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 V6 | 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. |
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 V6 | 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. |
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 V6 | 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. |
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 V6 | 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. |
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) | ||
| USCDI V6 | Medical Devices | Instrument, machine, appliance, implant, software, or similar device intended to be used for a medical purpose. |
Numeric or alphanumeric code that uniquely identifies a medical device. Usage note: Contains a device identifier (DI) and may contain one or more production identifiers (PI). |
|
Marti Velezis | FDA/CDRH/Indira Konduri (FDA/CDRH/OPEQ/ORP/DRPIII) | ||
| Draft USCDI V7 | Care Plans | 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. |
||||
| Draft USCDI V7 | Clinical Notes | Narrative patient data relevant to the context identified by note types.
|
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. |
|
|||
| Draft USCDI V7 | Clinical Notes | Narrative patient data relevant to the context identified by note types.
|
Discharge Summary Note |
Narrative summary of a patient’s admission and course in a hospital or post-acute care setting. Usage note: May 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. |
|
|||
| Draft USCDI V7 | 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. |
|
|||
| Draft USCDI V7 | Clinical Notes | Narrative patient data relevant to the context identified by note types.
|
Procedure Note |
Narrative summary of non-operative procedure. Examples include but are not limited to interventional cardiology, gastrointestinal endoscopy, and osteopathic manipulation. |
|
|||
| Draft USCDI V7 | Clinical Notes | Narrative patient data relevant to the context identified by note types.
|
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. |
|
|||
| Draft USCDI V7 | Goals and Preferences | Desired state to be achieved by a person or a person’s elections to guide care. |
Patient Goal |
Desired outcomes of patient’s care. Examples include but are not limited to blood pressure control, functional ability, nutrition, and food security. |
|
|||
| Draft USCDI V7 | Problems | Condition, diagnosis, or reason for seeking medical attention. |
Health Concern |
Health-related issue or worry. Examples include but are not limited to weight gain and cancer risk. |
||||
| Draft USCDI V7 | Immunizations | Record of vaccine administration. |
Immunization |
Vaccine product administered, planned, or reported. |
Both standards are required:
|
|||
| Draft USCDI V7 | Laboratory | Analysis of clinical specimens to obtain information about the health of a patient. |
Test |
Analysis of specimens derived from humans which provide information for the diagnosis, prevention, treatment of disease, or assessment of health. |
|
|||
| Draft USCDI V7 | Laboratory | Analysis of clinical specimens to obtain information about the health of a patient. |
Value/Result |
Documented findings of a tested specimen including structured and unstructured components. |
|
|||
| Draft USCDI V7 | Medications | Pharmacologic agents used in the diagnosis, cure, mitigation, treatment, or prevention of disease. |
Medication |
Pharmacologic agent used in the diagnosis, cure, mitigation, treatment, or prevention of disease. |
Optional:
|
|||
| Draft USCDI V7 | Patient Demographics/Information | Data used to categorize individuals for identification, records matching, and other purposes. |
First Name | |||||
| Draft USCDI V7 | Patient Demographics/Information | Data used to categorize individuals for identification, records matching, and other purposes. |
Last Name |