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 V3

Condition, diagnosis, or reason for seeking medical attention.

Problems
  • Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT®) U.S. Edition, January 2022 Release
  • International Classification of Diseases ICD-10-CM 2021
Draft USCDI V3

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

Phone Number

Both standards are required

  • ITU-T E.123, Series E: Overall Network Operation, Telephone Service, Service Operation and Human Factors, International operation - General provisions concerning users: Notation for national and international telephone numbers, email addresses and web addresses, February 2001
  • ITU-T E.164, Series E: Overall Network Operation, Telephone Service, Service Operation and Human Factors, International operation - Numbering plan of the international telephone service, The international public telecommunication numbering plan, November 2010

Adopted at 45 CFR 170.207(q)(1)

Draft USCDI V3

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

Related Person's Relationship

Represents the relationship between a patient and a person involved in the care of a patient (e.g., parent, next-of-kin, guardian, custodian).

Draft USCDI V3

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

Current Address

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

Draft USCDI V3

Activity performed for or on a patient as part of the provision of care.

Procedures
  • SNOMED International, Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT®) U.S. Edition, January 2022 Release
  • Current Procedural Terminology (CPT®) 2021, as maintained and distributed by the American Medical Association, for physician services and other health care services, and Healthcare Common Procedure Coding System (HCPCS), as maintained and distributed by HHS.
  • For technology primarily developed to record dental procedures: Code on Dental Procedures and Nomenclature (CDT), maintained and distributed by the American Dental Association, for dental services.

Optional:

  • International Classification of Diseases ICD-10-PCS 2021
Draft USCDI V3

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

Related Person's Name

The name of a person involved in the care of a patient, but who is not the target of that care.

CDC-defined HL70063

Nedra Garrett Centers for Disease Control and Prevention
Draft USCDI V3

Activity performed for or on a patient as part of the provision of care.

Reason for Referral

An explanation or justification for why this service is being requested or was provided.

Adam Bazer, MPD Integrating the Healthcare Enterprise USA (IHE USA)
Draft USCDI V3

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

Preferred Language

Request for Comment (RFC) 5646, “Tags for Identifying Languages”, September 2009

Adopted at 45 CFR 170.207(g)

Draft USCDI V3

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 2.71
  • The Unified Code of Units for Measure, Revision 2.1
Draft USCDI V3

Information related to interactions between healthcare providers and patients.

Encounter Diagnosis
  • SNOMED International, Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT®) U.S. Edition, January 2022 Release
  • International Classification of Diseases ICD-10-CM 2021
Joel Andress Centers for Medicare and Medicaid Services (CMS) Center for Clinical Standards and Quality (CCSQ)
Draft USCDI V3

Information related to interactions between healthcare providers and patients.

Encounter Disposition

Identifies the location or type of facility to where the patient left a hospital or encounter episode.

Joel Andress Centers for Medicare and Medicaid Services (CMS) Center for Clinical Standards and Quality (CCSQ)
Draft USCDI V3

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

Author Time Stamp
Draft USCDI V3

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

Date of Birth
Draft USCDI V3

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

Suffix
Draft USCDI V3

Condition, diagnosis, or reason for seeking medical attention.

Social Determinants of Health-related health concerns, conditions, or diagnoses. (e.g., homelessness, food insecurity)

  • SNOMED International, Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT®) U.S. Edition, March 2021 Release
  • International Classification of Diseases ICD-10-CM 2021
Mark Savage for Gravity Project Gravity Project
Draft USCDI V3

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

Gender Identity

A person’s internal sense of being a man, woman, both, or neither.

Gender Identify must be coded in accordance with SNOMED CT® and HL7 Version 3 Standard, Value Sets for AdministrativeGender and NullFlavor, attributed as follows:

  • Male. 446151000124109
  • Female. 446141000124107
  • Female-to-Male (FTM)/Transgender Male/Trans Man. 407377005
  • Male-to-Female (MTF)/Transgender Female/Trans Woman. 407376001
  • Genderqueer, neither exclusively male nor female. 446131000124102
  • Additional gender category or other, please specify. nullFlavor OTH
  • Choose not to disclose. nullFlavor ASKU

Adopted at 45 CFR 170.207(o)(2)

A. Taylor ONC
Draft USCDI V3

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 V3

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.

Smoking Status

Representing a patient’s smoking behaviors.

  • SNOMED International, Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT®) U.S. Edition, January 2022 Release
Draft USCDI V3

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

Specimen Type

Type of specimen (e.g., nasopharyngeal swab, whole blood, serum, urine, wound swab) on which a lab test is performed.

Nedra Garrett Centers for Disease Control and Prevention
Draft USCDI V3

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)