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
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

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

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

Previous Address

Includes street name, number, city/town, state, and zip code.

Draft USCDI V2

Health related matter that is of interest, importance, or worry to someone who may be the patient, patient’s family or patient’s health care provider.

Health Concerns
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

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

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

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

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

Respiratory Rate
  • Logical Observation Identifiers Names and Codes (LOINC®) version 2.69
  • The Unified Code of Units for Measure (UCUM), Revision 2.1
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. 
Progress Note

Represents a patient’s interval status during a hospitalization, outpatient visit, treatment with a post-acute care provider, or other healthcare encounter.

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

  • Progress Note (LOINC® code 11506-3)
Draft USCDI V2

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

Middle Name (Including middle initial)
Draft USCDI V2

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

Body Temperature
  • 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 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)
Draft USCDI V2

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

Sex (Assigned at Birth)

Birth sex must be coded in accordance with HL7 Version 3 (V3) Standard, Value Sets for AdministrativeGender and NullFlavor attributed as follows:

  • Female. F
  • Male. M
  • Unknown. nullFlavor UNK

Adopted at 45 CFR 170.207(n) 

Draft USCDI V2

Information related to interactions between healthcare providers and a patient.

Encounter Type Joel Andress Centers for Medicare and Medicaid Services (CMS) Center for Clinical Standards and Quality (CCSQ)
Draft USCDI V2

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

Weight-for-length 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

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

Pulse Oximetry
  • 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
Draft USCDI V2

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

Suffix
Draft USCDI V2

Health professional’s conclusions and working assumptions that will guide treatment of the patient.

Assessment and Plan of Treatment
Draft USCDI V2

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

BMI Percentile (2 - 20 years)
  • Logical Observation Identifiers Names and Codes (LOINC®) version 2.69
  • The Unified Code of Units for Measure (UCUM), Revision 2.1