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
Draft USCDI V2

Information about a person who participates or is expected to participate in the care of a patient.

 Care Team Member Name Al Taylor ONC
Draft USCDI V2

Information about a person who participates or is expected to participate in the care of a patient.

 Care Team Member Identifier Al Taylor ONC
Draft USCDI V2

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

 Last Name
Draft USCDI V2

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)
Draft USCDI V2

Record of vaccine administration.

 Immunizations
  • CDC IIS: Current HL7 Standard Code Set, CVX -- Vaccines Administered, updates through November 16, 2020
  • CDC National Drug Code (NDC) Directory – Vaccine NDC Linker Table, updates through November 13, 2020
Draft USCDI V2

Tests that result in visual images requiring interpretation by a credentialed professional.

 Imaging Narrative

Contains a consulting specialist’s interpretation of diagnostic imaging data.

This data element was reclassified from Clinical Notes to Diagnostic Imaging.

Logical Observation Identifiers Names and Codes (LOINC®) version 2.69

  • Diagnostic Imaging Study (LOINC® code 18748-4
Draft USCDI V2

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 2.69
  • The Unified Code of Units for Measure (UCUM), Revision 2.1
Draft USCDI V2

Harmful or undesired physiological responses associated with exposure to a substance.

 Substance (Medication)
  • RxNorm®, January 4, 2021 Full Release Update
Draft USCDI V2

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

 Procedures
  • Healthcare Common Procedure Coding System (HCPCS)
  • Current Procedural Terminology (CPT), 2021
  • Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT®) U.S. Edition, September 2020 Release
  • For technology primarily developed to record dental procedures: Code on Dental Procedures and Nomenclature (CDT), maintained and distributed by the American Dental Association, for dental services.

Optional:

  • International Classification of Diseases ICD-10-PCS 2021
Draft USCDI V2

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

 Phone Number Type
Draft USCDI V2

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

 Author Time Stamp
Draft USCDI V2

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

 Medications
  • RxNorm®, January 4, 2021 Full Release Update
Draft USCDI V2

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

 Author Organization

Organization associated with author.
Draft USCDI V2

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.
Draft USCDI V2

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

 Head Occipital-frontal Circumference Percentile (Birth - 36 Months)
  • Logical Observation Identifiers Names and Codes (LOINC®) version 2.69
  • The Unified Code of Units for Measure (UCUM), Revision 2.1
Draft USCDI V2

Condition, diagnosis, or reason for seeking medical attention.

 Problems
  • Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT®) U.S. Edition, September 2020 Release
Draft USCDI V2

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 2020 Release
Draft USCDI V2

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

 First Name
Draft USCDI V2

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 2.69
Draft USCDI V2

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

 Email Address