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
Level 0 Medications

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

Medication Start/End Date

The start and end date of a medication order.

Sandi Mitchell J P Systems, Inc.
Level 0 Nutrition and Diet Oral Diet Nutrient Modifiers Nutrients that are increased or decreased in conjunction with the oral diet type as part of a therapeutic diet. For example, “decreased sodium” or “increased protein”.

HL7 Version 2 – ODS – Dietary orders, supplements, and preferences (http://www.hl7.org/implement/standards/product_brief.cfm?product_id=185) HL7 Version 3 Standard: Orders; Diet and Nutrition, Release 1 (http://www.hl7.org/implement/standards/product_brief.cfm?product_id=317) HL7 FHIR NutritionOrder (https://www.hl7.org/fhir/nutritionorder.html) In addition, many there are many nutrition-related terms in SNOMED CT. Many of these terms have been put in value sets in VSAC or through HL7 terminology. Here are some examples: Diet Type (OID 2.16.840.1.113883.4.642.3.385) – HL7 terminology Nutrient Modifier (OID 2.16.840.1.113883.4.642.3.386) – HL7 terminology Nutrition Supplement (OID 2.16.840.1.113883.4.642.3.390) – HL7 terminology Enteral Nutrition Type (OID 2.16.840.1.113883.4.642.3.391) – HL7 terminology Enteral Nutrition Additive (OID 2.16.840.1.113883.4.642.3.392) – HL7 terminology Food Allergies and Intolerance (OID 2.16.840.1.113762.1.4.1186.3) - VSAC Feeding Device Grouping (OID 2.16.840.1.113762.1.4.1095.87) - VSAC

Becky Gradl Academy of Nutrition and Dietetics
Level 0 Patient Demographics/Information

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

Country of Usual Residence

The patient’s usual country of residence

HL7 FHIR® Implementation Guide: Electronic Case Reporting (eCR) based on FHIR R4 HL7 CDA® R2 Implementation Guide: Public Health Case Report - the Electronic Initial Case Report (eICR) HL7 FHIR: Country of Residence profile HL7 CDA: Country of Residence template

Laura Conn
Level 0 Goals and Preferences

Desired state to be achieved by a person or a person’s elections to guide care.

Religious & Spiritual Preferences

Defines an individual's religious or spiritual preferences which helps to support whole-person care in the in-patient and out-patient settings as well as in the palliative and end-of-life care settings.

Grace Cordovano Enlightening Results
Level 0 Explanation of Benefit

Health data as reflected in a patient's Explanation of Benefits (EOB) statements, typically derived from claims and other administrative data.

Claim Service Start Date

Date on which services began.

NUBC, CPT, HCPCS, HIPPS, ICD-9, ICD-10, DRGs, NDC, POS, NCPDP codes, and X12 codes.

Mark Roberts Leavitt Partners
Level 0 Explanation of Benefit

Health data as reflected in a patient's Explanation of Benefits (EOB) statements, typically derived from claims and other administrative data.

Procedure Code Type

Indicates if the inpatient institutional procedure (ICD-PCS) is the principal procedure or another procedure

NUBC, CPT, HCPCS, HIPPS, ICD-9, ICD-10, DRGs, NDC, POS, NCPDP codes, and X12 codes.

Mark Roberts Leavitt Partners
Level 0 Explanation of Benefit

Health data as reflected in a patient's Explanation of Benefits (EOB) statements, typically derived from claims and other administrative data.

Procedure Type

Additional surgical procedure a patient received during inpatient stay. Coding methods for this field is International Classification of Diseases Surgical Procedures (ICD-10).

NUBC, CPT, HCPCS, HIPPS, ICD-9, ICD-10, DRGs, NDC, POS, NCPDP codes, and X12 codes.

Mark Roberts Leavitt Partners
Level 0 Explanation of Benefit

Health data as reflected in a patient's Explanation of Benefits (EOB) statements, typically derived from claims and other administrative data.

Modifier Code -1

Modifier(s) for the procedure represented on this line. Identifies special circumstances related to the performance of the service.

NUBC, CPT, HCPCS, HIPPS, ICD-9, ICD-10, DRGs, NDC, POS, NCPDP codes, and X12 codes.

Mark Roberts Leavitt Partners
Level 0 Explanation of Benefit

Health data as reflected in a patient's Explanation of Benefits (EOB) statements, typically derived from claims and other administrative data.

Modifier Code -2

Modifier(s) for the procedure represented on this line. Identifies special circumstances related to the performance of the service.

NUBC, CPT, HCPCS, HIPPS, ICD-9, ICD-10, DRGs, NDC, POS, NCPDP codes, and X12 codes.

Mark Roberts Leavitt Partners
Level 0 Explanation of Benefit

Health data as reflected in a patient's Explanation of Benefits (EOB) statements, typically derived from claims and other administrative data.

Modifier Code -3

Modifier(s) for the procedure represented on this line. Identifies special circumstances related to the performance of the service.

NUBC, CPT, HCPCS, HIPPS, ICD-9, ICD-10, DRGs, NDC, POS, NCPDP codes, and X12 codes.

Mark Roberts Leavitt Partners
Level 0 Explanation of Benefit

Health data as reflected in a patient's Explanation of Benefits (EOB) statements, typically derived from claims and other administrative data.

Modifier Code -4

Modifier(s) for the procedure represented on this line. Identifies special circumstances related to the performance of the service.

NUBC, CPT, HCPCS, HIPPS, ICD-9, ICD-10, DRGs, NDC, POS, NCPDP codes, and X12 codes.

Mark Roberts Leavitt Partners
Level 0 Explanation of Benefit

Health data as reflected in a patient's Explanation of Benefits (EOB) statements, typically derived from claims and other administrative data.

Claim Paid Date

The date the claim was paid.

NUBC, CPT, HCPCS, HIPPS, ICD-9, ICD-10, DRGs, NDC, POS, NCPDP codes, and X12 codes.

Mark Roberts Leavitt Partners
Level 0 Explanation of Benefit

Health data as reflected in a patient's Explanation of Benefits (EOB) statements, typically derived from claims and other administrative data.

Claim Service End Date

Date on which services ended.

NUBC, CPT, HCPCS, HIPPS, ICD-9, ICD-10, DRGs, NDC, POS, NCPDP codes, and X12 codes.

Mark Roberts Leavitt Partners
Level 0 Laboratory

Analysis of clinical specimens to obtain information about the health of a patient.

Test Kit Unique Device Identifier Uniquely identifies the type of test (at minimum by using test name and manufacturer (similar to the make and model of a car)) that was used to obtain the Test Result Value. It is a device identifier and should be referenced using Device Identifiers (DI), when available. The DI is contained within the unique device identifier (UDI), created by manufacturer (Manufacturer requests UDI issuance, then provides DI, or can be pulled from GUDID database (https://accessgudid.nlm.nih.gov/) Riki Merrick Association of Public Health Laboratories
Level 0 Patient Demographics/Information

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

Tribal Enrollment

A tribe of which the patient is an enrolled member.

HL7 FHIR: US Public Health Tribal Affiliation extension
HL7 CDA: Tribal Affiliation template
HL7 Value Set: TribalEntityUS

Laura Conn
Level 0 Care Team Members

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

Proxy Decision Maker

Individual designated by the patient to make healthcare decisions for the patient in the event the patient is unable.

Holly Miller, MD MedAllies
Level 0 Clinical Tests

Non-imaging and non-laboratory tests performed that result in structured or unstructured findings specific to the patient to facilitate the diagnosis and management of conditions.

Audiogram

Standard under development by HL7 in Diagnostic Audiology Reporting HL7 V2 Implementation Guide
https://confluence.hl7.org/display/PHWG/Diagnostic+Audiology+Reporting+…
Subset of this implementation guide that = Audiogram is
•Diagnostic audiology tests performed
•Results of the diagnostic evaluation: left ear, including type, severity, and configuration of hearing loss, if a diagnosis is made.
•Results of the diagnostic evaluation: right ear, including type, severity, and configuration of hearing loss, if a diagnosis is made.
•Results of diagnostic evaluation in the form of audiogram

Troy Kaji Contra Costa Health Services
Level 0 Laboratory

Analysis of clinical specimens to obtain information about the health of a patient.

Accession number

The unique identifier for a single instance of a specimen received by a laboratory and its analysis.

Riki Merrick Association of Public Health Laboratories
Level 0 Vital Signs

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

Urine Output The total urine output during a calendar day, from all sources including voids, bladder catherization, urostomy, nephrostomy tubes.

LOINC 9097-7 Fluid balance 24hrs SNOMED CT 251856003 Fluid balance

Ali Abbas MD UCSF
Level 0 Vital Signs

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

Total Intake The total volume that the patient received during a calendar day, through all sources of access (e.g. intravenous, enteral, oral, peritoneal, pleural, intrathecal, intravesicular, rectal)

LOINC 9097-7 Fluid balance 24hrs SNOMED CT 251856003 Fluid balance

Ali Abbas MD UCSF