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

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

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

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

Care Team Member
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

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

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

Date of Birth
Draft USCDI V2

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

Middle Name (Including middle initial)
Draft USCDI V2

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

Pathology Report Narrative

Contains a consulting specialist’s interpretation of the pathology report.

This data element was reclassified from Clinical Notes to Laboratory.

Draft USCDI V2

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

Laboratory Report Narrative

Contains a consulting specialist’s interpretation of the laboratory report.

This data element was reclassified from Clinical Notes to Laboratory.

Draft USCDI V2

Narrative patient data relevant to the context identified by note types.

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  • 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.

Phone Number Type
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

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

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

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

Narrative patient data relevant to the context identified by note types.

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  • 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. 
History & Physical

Documents the current and past conditions and observations of the patient.

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

  • History and Physical Note (LOINC code 34117-2)
Draft USCDI V2

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

Previous Name
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

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

Last Name
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

Narrative patient data relevant to the context identified by note types.

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  • 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. 
Procedure Note

Encompasses non-operative procedures including interventional cardiology, gastrointestinal endoscopy, osteopathic manipulation, and other specialty’s procedures.

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

  • Procedure Note (LOINC® code 28570-0)