USCDI Export for the Public

APGAR score post-birth including scores at 1, 5 and 10 minutes.

LOINC codes exist for each of the proposed data elements: 11884-4 - Gestational age Estimated 73766-8 - Place where birth occurred [US Standard Certificate of Live Birth] 64710-7 - Was your pregnancy a live birth, stillbirth, miscarriage, abortion, or ectopic pregnancy [PhenX] 8339-4 - Birth weight Measured 8305-5 - Body height --post partum 9272-6 - 1 minute Apgar Score 9274-2 - 5 minute Apgar Score 9271-8 - 10 minute Apgar Score

The hearing screening result for the leftear provides coded result values for pass, refer and not performed. There should be separate results for both the right Ear and left ear.

54108-6 - Newborn hearing screen of Ear - left (including Preferred Answer List LL618-0)

The number of fetal deaths in this delivery.

LOINC codes exist for each of the proposed data elements: 69461-2 - Mother's body weight --at delivery 68493-6 - Prenatal visits for this pregnancy # 69044-6 - Date first prenatal visit 57722-1 - Birth plurality of Pregnancy 73772-6 - Number of fetal deaths delivered 73773-4 - Number of infants in this delivery delivered alive

This data element carries information on Self-care that is exchanged as observations. (Observations are characteristics that can be tested, measured, or observed and are communicated with a name-value pair structure). Self-care is a broad domain. Using the conceptual framework of the the International Classification of Function (ICF), it includes aspects such as eating, caring for teeth, putting clothes on, etc. Notes: • This data element is constrained to health data represented in data structures for observations. Observations should be represented using terminologies supporting this conceptual model, such as LOINC, which is designed for this purpose. Representing problems, goals, and other types of information related to functioning should use other data class structures as appropriate. • Examples of Self-care concepts can be found in the ICF browser at: https://apps.who.int/classifications/icfbrowser • Examples of demonstrated use of Self-care data can be found in the PACIO FHIR Functional Status Implementation Guide which supports exchange of observation data such as eating, oral hygiene, upper body dressing using assessments coded with LOINC.

LOINC. LOINC is a freely available global standard that contains a well-developed model for representing variables, answer lists, and the collections that contain them.* Many clinical assessments, scales, and other observations related to functioning are present in LOINC, including all of the variables on the PAC assessments for SNFs, IRFs, LTCHs, and HHAs. Regenstrief operates a robust process for adding new content (including functioning assessment instruments) if key gaps are identified. *PMID: 22899966

The hearing screening result for the right ear provides coded result values for pass, refer and not performed. There should be separate results for both the right Ear and left ear.

54109-4 - Newborn hearing screen of Ear - right (including Preferred Answer List LL618-0)

Representation of the content produced in a DICOM imaging study. A study comprises a set of series, each of which includes a set of Service-Object Pair Instances (SOP Instances - images or other data) acquired or produced in a common context. A series is of only one modality (e.g. X-ray, CT, MR, ultrasound), but a study may have multiple series of different modalities.

DICOM

This data element carries information on Mobility that is exchanged as observations. (Observations are characteristics that can be tested, measured, or observed and are communicated with a name-value pair structure). Mobility is a broad domain. Using the conceptual framework of the International Classification of Function (ICF), it includes aspects such as rolling over, transferring, walking short distances, etc. Notes: • This data element is constrained to health data represented in data structures for observations. Observations should be represented using terminologies supporting this conceptual model, such as LOINC, which is designed for this purpose. Representing problems, goals, and other types of information related to functioning should use other data class structures as appropriate. • Examples of Mobility concepts can be found in the ICF browser at: https://apps.who.int/classifications/icfbrowser • Examples of demonstrated use of Mobility data can be found in the PACIO FHIR Functional Status Implementation Guide which supports exchange of observation data such as roll left and right, car transfer, walk 10 feet using assessments coded with LOINC.

LOINC. LOINC is a freely available global standard that contains a well-developed model for representing variables, answer lists, and the collections that contain them.* Many clinical assessments, scales, and other observations related to functioning are present in LOINC, including all of the variables on the PAC assessments for SNFs, IRFs, LTCHs, and HHAs. Regenstrief operates a robust process for adding new content (including functioning assessment instruments) if key gaps are identified. *PMID: 22899966

The date when the prescription was initially written or authored.

Date Medication Prescribed and Date Medication Administered: dateTime Data Type (FHIR): http://hl7.org/fhir/datatypes.html#dateTime Medication Prescribed Code and Medication Administered Code: RxNorm: https://www.nlm.nih.gov/research/umls/rxnorm/index.html Medication Prescribed Dose Units and Medication Administration Dose Units: UCUM: http://unitsofmeasure.org

A code (or set of codes) that specify this medication, or a textual description if no code is available.

Date Medication Prescribed and Date Medication Administered: dateTime Data Type (FHIR): http://hl7.org/fhir/datatypes.html#dateTime Medication Prescribed Code and Medication Administered Code: RxNorm: https://www.nlm.nih.gov/research/umls/rxnorm/index.html Medication Prescribed Dose Units and Medication Administration Dose Units: UCUM: http://unitsofmeasure.org

Indicates the amount of medication per dose that is to be used by the patient.

Date Medication Prescribed and Date Medication Administered: dateTime Data Type (FHIR): http://hl7.org/fhir/datatypes.html#dateTime Medication Prescribed Code and Medication Administered Code: RxNorm: https://www.nlm.nih.gov/research/umls/rxnorm/index.html Medication Prescribed Dose Units and Medication Administration Dose Units: UCUM: http://unitsofmeasure.org

ICD 10, SNOMED, LOINC, RxNorm

Was a of surgery used as part of treatment for this diagnosis (e.g., Yes, No, Indeterminant)?
This is important minimal set information needed for coordinated care and understanding outcomes for public health policy

American Joint Committee on Cancer e.g. AJCC8

Was a of systemic therapy used as part of treatment for this diagnosis?
Yes
No
Indeterminant

American Joint Committee on Cancer e.g. AJCC8

Was a of radiation therapy used as part of treatment for this diagnosis ? This is important minimal set information needed for coordinated care and understanding outcomes for public health policy
Yes
No
Indeterminant

American Joint Committee on Cancer e.g. AJCC8

The date the individual when they stopped nicotine consumption/use. Business rule: If quit date is within the last 30 days there should be a full date. If not, partial dates are accepted, or if null look for Quit Age

There are SNOMED and LOINC Codes for most of the data elements but new codes will be requested for eCigarette use.

The patient’s pack-years of smoking, or the information needed to determine the pack-years (e.g., packs per day and years of smoking).

Unified Code for Untis of Measure (UCUM) units for pack years and packs per day. There is also a LOINC code for packs per day (8663-7) and years smoked (88029-4).

The age of the individual when they stopped nicotine consumption/use. Question Prompt: Age stopped nicotine consumption/use.

There are SNOMED and LOINC Codes for most of the data elements but new codes will be requested for eCigarette use.

The age of the individual when they started nicotine consumption/use. Question Prompt: Age started nicotine consumption/use.

There are SNOMED and LOINC Codes for most of the data elements but new codes will be requested for eCigarette use.

Defines if the radiation therapy structure a target structure (e.g. PTV, CTV, GTV) or an organ at risk.

Standard Values (List): Target; Organ at Risk

Indicates the reason the immunization event was not performed.

Immunization Code: CVX: Vaccines Administered 2.16.840.1.113762.1.4.1010.6: https://vsac.nlm.nih.gov/valueset/2.16.840.1.113762.1.4.1010.6/expansion Immunization Code: National Drug Codes (NDC): http://www2a.cdc.gov/vaccines/iis/iisstandards/ndc_tableaccess.asp Immunization Status: FHIR Immunization Status Codes: http://hl7.org/fhir/ValueSet/immunization-status Immunization Administered Date: FHIR datatypes: dateTime, String: https://www.hl7.org/fhir/us/core/StructureDefinition-us-core-immunization-definitions.html#Immunization.occurrence[x] Reason Immunization Not Performed: FHIR Immunization Status Reason Codes: http://hl7.org/fhir/R4/valueset-immunization-status-reason.html