USCDI Export for the Public

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Classification Level Data Class Data Class Description Data Element Data Element Description Applicable Standards Submitter Name Submitter Organization Submission Date
USCDI V1 Vital Signs

Physiologic measurements of a patient that indicate the status of the body’s life sustaining functions.

 Body Height
  • Logical Observation Identifiers Names and Codes (LOINC®) version 2.67
  • The Unified Code of Units for Measure (UCUM), Revision 2.1
USCDI V1 Immunizations

Record of vaccine administration.

 Immunizations
  • CDC IIS: Current HL7 Standard Code Set, CVX -- Vaccines Administered, updates through January 31, 2020
  • CDC National Drug Code (NDC) Directory – Vaccine NDC Linker Table, updates through January 31, 2020
USCDI V1 Vital Signs

Physiologic measurements of a patient that indicate the status of the body’s life sustaining functions.

 Systolic Blood Pressure

Both standards are required.

  • Logical Observation Identifiers Names and Codes (LOINC®) version 2.67
  • The Unified Code of Units for Measure (UCUM), Revision 2.1
USCDI V1 Patient Demographics/Information

Data used to categorize individuals for identification, records matching, and other purposes.

 Preferred Language

Request for Comment (RFC) 5646, “Tags for Identifying Languages”, September 2009

Adopted at 45 CFR 170.207(g)
USCDI V1 Patient Demographics/Information

Data used to categorize individuals for identification, records matching, and other purposes.

 Last Name
USCDI V1 Patient Demographics/Information

Data used to categorize individuals for identification, records matching, and other purposes.

 Previous Name
USCDI V1 Patient Demographics/Information

Data used to categorize individuals for identification, records matching, and other purposes.

 Middle Name (Including middle initial)
USCDI V1 Patient Demographics/Information

Data used to categorize individuals for identification, records matching, and other purposes.

 Suffix
USCDI V1 Patient Demographics/Information

Data used to categorize individuals for identification, records matching, and other purposes.

 First Name
USCDI V1 Patient Demographics/Information

Data used to categorize individuals for identification, records matching, and other purposes.

 Birth Sex

Birth sex must be coded in accordance with HL7 Version 3 (V3) Standard, Value Sets for AdministrativeGender and NullFlavor attributed as follows:

  • Female. F
  • Male. M
  • Unknown. nullFlavor UNK

Adopted at 45 CFR 170.207(n) 
USCDI V1 Patient Demographics/Information

Data used to categorize individuals for identification, records matching, and other purposes.

 Date of Birth
USCDI V1 Patient Demographics/Information

Data used to categorize individuals for identification, records matching, and other purposes.

 Race

Both standards are required

  • The Office of Management and Budget Standards for Maintaining, Collecting, and Presenting Federal Data on Race and Ethnicity, Statistical Policy Directive No. 15, as revised, October 30, 1997
  • CDC Race and Ethnicity Code Set Version 1.0 (March 2000)

Adopted at 45 CFR 170.207(f)
USCDI V1 Patient Demographics/Information

Data used to categorize individuals for identification, records matching, and other purposes.

 Ethnicity

Both standards are required:

  • The Office of Management and Budget Standards for Maintaining, Collecting, and Presenting Federal Data on Race and Ethnicity, Statistical Policy Directive No. 15, as revised, October 30, 1997
  • CDC Race and Ethnicity Code Set Version 1.0 (March 2000)

Adopted at 45 CFR 170.207(f)
USCDI V1 Medications

Pharmacologic agents used in the diagnosis, cure, mitigation, treatment, or prevention of disease.

 Medications
  • RxNorm®, January 6, 2020 Full Release Update
USCDI V1 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.
  • Logical Observation Identifiers Names and Codes (LOINC®) version 2.67
USCDI V1 Provenance

The metadata, or extra information about data, regarding who created the data and when it was created.

 Author Time Stamp
USCDI V1 Provenance

The metadata, or extra information about data, regarding who created the data and when it was created.

 Author Organization

Organization associated with author.
USCDI V1 Procedures

Activity performed for or on a patient as part of the provision of care.

 Procedures
  • Healthcare Common Procedure Coding System (HCPCS)
  • Current Procedural Terminology, Fourth Edition (CPT-4)
  • Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT®) U.S. Edition, September 2019 Release

Optional:

  • USCDI v1 - International Classification of Diseases ICD-10-PCS 2020

Optional for technology which records dental procedures:

  • Code on Dental Procedures and Nomenclature (CDT), maintained and distributed by the American Dental Association, for dental services.
USCDI V1 Smoking Status

Representing a patient’s smoking behavior.

 Smoking Status

Representing a patient’s smoking behaviors.
  • SNOMED International, Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT®) U.S. Edition, September 2019 Release
USCDI V1 Unique Device Identifier(s) for a Patient's Implantable Device(s)

Unique identifier(s) for a patient's implantable device(s).

 Unique Device Identifier(s) for a patient's implantable device(s) Marti Velezis FDA/CDRH/Indira Konduri (FDA/CDRH/OPEQ/ORP/DRPIII)