USCDI Export for the Public

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Classification Level Sort descending	Data Class Description	Data Element	Data Element Description	Applicable Standards	Submitter Name	Submitter Organization	Submission Date
Draft USCDI V2	Narrative patient data relevant to the context identified by note types. Usage note: Clinical Notes data elements are content exchange standard agnostic. They should not be interpreted or associated with the structured document templates that may share the same name.	Discharge Summary Note	A synopsis of a patient’s admission and course in a hospital or post-acute care setting.	Logical Observation Identifiers Names and Codes (LOINC®) version 2.69 Discharge Summary (LOINC® code 18842-5)
Draft USCDI V2	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)
Draft USCDI V2	Physiologic measurements of a patient that indicate the status of the body’s life sustaining functions.	Body Weight		Logical Observation Identifiers Names and Codes (LOINC®) version 2.69 The Unified Code of Units for Measure (UCUM), Revision 2.1
Draft USCDI V2	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 2.69 The Unified Code of Units for Measure (UCUM), Revision 2.1
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	10/10/2020 - 02:26
Draft USCDI V2	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)
Draft USCDI V2	Information related to interactions between healthcare providers and a patient.	Encounter Time	Represents a date/time related to an encounter (e.g., scheduled appointment time, check in time, start and stop times).		Joel Andress	Centers for Medicare and Medicaid Services (CMS) Center for Clinical Standards and Quality (CCSQ)	10/02/2020 - 08:35
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	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	Condition, diagnosis, or reason for seeking medical attention.	Date of Diagnosis	Date of first determination by a qualified professional of the presence of a problem or condition affecting a patient.		Steven Lane	Sutter Health	09/11/2020 - 05:08
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	Narrative patient data relevant to the context identified by note types. Usage note: Clinical Notes data elements are content exchange standard agnostic. They should not be interpreted or associated with the structured document templates that may share the same name.	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 2.69 Consult Note (LOINC® code 11488-4)
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		Both standards are required ITU-T E.123, Series E: Overall Network Operation, Telephone Service, Service Operation and Human Factors, International operation - General provisions concerning users: Notation for national and international telephone numbers, email addresses and web addresses, February 2001 ITU-T E.164, Series E: Overall Network Operation, Telephone Service, Service Operation and Human Factors, International operation - Numbering plan of the international telephone service, The international public telecommunication numbering plan, November 2010 Adopted at 45 CFR 170.207(q)(1)
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	Data used to categorize individuals for identification, records matching, and other purposes.	Current Address	Includes street name, number, city/town, state, and zip code.
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	Unique identifier(s) for a patient's implantable device(s).			UDI identifier as described by applicable FDA regulation. https://www.fda.gov/medical-devices/unique-device-identification-system-udi-system/udi-rule-and-guidances-training-resources-and-dockets#rule	Marti Velezis	FDA/CDRH/Indira Konduri (FDA/CDRH/OPEQ/ORP/DRPIII)	09/17/2024 - 21:27
Draft USCDI V2	Physiologic measurements of a patient that indicate the status of the body’s life sustaining functions.	Diastolic 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