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 Provenance

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

Report Submission Date/Time

The date and time at which the EHR system sends the report.

Sarah Gaunt The Association of Public Health Laboratories (APHL)
Level 0 Newborn's Delivery Information Reason CCHD oxygen saturation screening not performed

The reason that CCHD screening for newborns was not performed on this patient.

LOINC 73698-3 - Reason CCHD oxygen saturation screening not performed (including Preferred Answer List LL2458-9)

Craig Newman Altarum
Level 0 Special Alerts for Care Handoffs Scheduling (time specific interventions) LOINC

Indicate timing for scheduling essential testing, treatments, consults, procedures, and follow-up appointments.

ICD 10, SNOMED, LOINC, RxNorm

Holly Miller, MD MedAllies
Level 0 Special Alerts for Care Handoffs Patient behaviors with risk to self or others (reported or observed) ICD 10, SNOMED

Examples Include:
Wandering Z91.83
Falls Z91.81
Confusion F05
Aggressive behavior F02.81
Physical violence R45.6
Suicidal ideation R45.851

ICD 10, SNOMED, LOINC, RxNorm

Holly Miller, MD MedAllies
Level 0 Patient Summary and Plan

Information that guides treatment of the patient and recommendations for future treatment.

Clinical Decision Support Data

Data and reporting used for risk stratification, optimization of patient outcomes, detection of decompensation, clinical and patient education.

SNOMED CT

Grace Cordovano Enlightening Results
Level 0 Care Team Members

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

Caregiver of disabled person

Person serving as a primary caregiver for a disabled person.

American Community Survey disability value set

Charles Mayo University of Michigan, American Association of Physicists in Medicine
Level 0 Adverse Events

Unintended effects associated with clinical interventions.

Oncology Adverse events

complications (serious- hospitalization, death)

Laura Esserman University of California - San Francisco
Level 0 Special Alerts for Care Handoffs Risk Scores LACE - https://www.mdcalc.com/calc/3805/lace-index-readmission

ICD 10, SNOMED, LOINC, RxNorm

Holly Miller, MD MedAllies
Level 0 Encounter Information

Information related to interactions between healthcare providers and a patient.

Slot

A slot of time on a schedule that may be available for booking appointments.

Philip Lieberman Analog Informatics Corporation
Level 0 Appointment Schedule

A container for slots of time that may be available for booking appointments.

Philip Lieberman Analog Informatics Corporation
Level 0 Social Determinants of Health SDOH Protective Factors

Social determinants of health-related characteristics or strengths of individuals, families that act to mitigate risks and promote positive well-being and healthy development

SNOMED CT

Sarah Candace DeSilvey Gravity Project
Level 0 Facility Information

Physical place of available services or resources.

Performing Facility

Name of the facility that completes the order

Jessi Lott Tennessee Department of Health
Level 0 Facility Information

Physical place of available services or resources.

Ordering Facility

Name of facility that is placing order

Jessi Lott Tennessee Department of Health
Level 0 Provenance

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

Set Id

An identifier that is common across all document revisions.

Sarah Gaunt The Association of Public Health Laboratories (APHL)
Level 0 Pregnancy Information Pregnancy risk

The pregnancy risk data element is represented by the LOINC code: 42838-3 with the variable values of: • Improved • Deteriorated • Stabilized

Ravi Kafle Washington State Department of Health
Level 0 Health Status Assessments

Assessments of a health-related matter of interest, importance, or worry to a patient, patient’s authorized representative, or patient’s healthcare provider that could identify a need, problem, or condition.

Goal Assessment

The assessment and monitoring of goals and goal progress.

Examples for goal assessments include Goal Attainment Scaling (GAS) and patient-reported outcome measures (PROMs) such as PHQ-9, GAD-7 or PROMIS.

Standardized goal assessment tools exist and have associated LOINC terminology codes.

Examples:
• 107332-9-- Goal attainment scale – Reported
• 107334-5 -- Patient follow-up goal attainment scaling score
• 107333-7-- Practitioner follow-up goal attainment scaling score
• 77854-8 -- PROMIS© Ability to Participate in Social Roles and Activities - Short Form v2.0 - 8a
• 92418-3 -- PROMIS© Self-Efficacy for Managing Medications and Treatments - Short Form v1.0 - 8a
• 70274-6-- General Anxiety Disorder (GAD) - 7
• 44261-6 -- PHQ-9

Grace Glennon-Jubrey (NCQA) NCQA
Level 0 Provenance

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

Case Report Version Number

An integer value used to version successive replacement documents of an electronic case report.

Sarah Gaunt The Association of Public Health Laboratories (APHL)
Level 0 Social Determinants of Health Congregate Living Shared housing includes a broad range of settings, such as apartments, condominiums, student or faculty housing, national and state park staff housing, transitional housing, and domestic violence and abuse shelters

HL7 CDA: C-CDA Characteristics of Home Environment template HL7 FHIR: US Public Health Characteristics of Home Environment LOINC: 75274-1 "Characteristics of residence" Value set: https://vsac.nlm.nih.gov/valueset/2.16.840.1.113883.11.20.9.49/expansion (Residence and Accommodation Type)

Nedra Garrett CDC
Level 0 Provenance

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

Custodian Organization Telecom

A telecom of the custodian organization.

Sarah Gaunt The Association of Public Health Laboratories (APHL)
Level 0 Provenance

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

Custodian Organization Id

An identifier of the custodian organization.

Sarah Gaunt The Association of Public Health Laboratories (APHL)