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 |
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| Draft USCDI V2 | Physiologic measurements of a patient that indicate the status of the body’s life sustaining functions. |
Body Temperature |
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| 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. |
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| 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. |
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| Draft USCDI V2 | Narrative patient data relevant to the context identified by note types.
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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
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| 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) |
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| 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
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| Draft USCDI V2 | Harmful or undesired physiological responses associated with exposure to a substance. |
Substance (Medication) |
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| Draft USCDI V2 | Narrative patient data relevant to the context identified by note types.
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History & Physical | Documents the current and past conditions and observations of the patient. |
Logical Observation Identifiers Names and Codes (LOINC®) version 2.69
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| 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 |
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| Draft USCDI V2 | Narrative patient data relevant to the context identified by note types.
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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
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