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 | Information related to interactions between healthcare providers and a patient. |
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 | Information about a person who participates or is expected to participate in the care of a patient. |
Care Team Member Telecom | Electronic contact information of a provider or other care team member |
|
Keith W. Boone | Audacious Inquiry | ||
| Draft USCDI V3 | Data used to categorize individuals for identification, records matching, and other purposes. |
Sexual Orientation | A person’s identification of their emotional, romantic, sexual, or affectional attraction to another person |
Sexual orientation must be coded in accordance with SNOMED CT® and HL7 Version 3 Standard, Value Sets for AdministrativeGender and NullFlavor, attributed as follows:
Adopted at 45 CFR 170.207(o)(1) |
A. Taylor | ONC | ||
| Draft USCDI V3 | Data used to categorize individuals for identification, records matching, and other purposes. |
Date of Birth | ||||||
| Draft USCDI V3 | Unique identifier(s) for a patient's implantable device(s). |
|
Marti Velezis | FDA/CDRH/Indira Konduri (FDA/CDRH/OPEQ/ORP/DRPIII) | ||||
| Draft USCDI V3 | Health professional’s conclusions and working assumptions that will guide treatment of the patient. |
Assessment and Plan of Treatment | ||||||
| Draft USCDI V3 | Physiologic measurements of a patient that indicate the status of the body’s life sustaining functions. |
Body Weight |
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| Draft USCDI V3 | Information related to interactions between healthcare providers and a patient. |
Encounter Location | Location of facility which delivered a person’s health care or related services |
Joel Andress | Centers for Medicare and Medicaid Services (CMS) Center for Clinical Standards and Quality (CCSQ) | |||
| 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). |
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| Draft USCDI V3 | Desired state to be achieved by a patient. |
Patient Goals | Desired outcomes of patient's care. |
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| Draft USCDI V3 | 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 2.71
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| Draft USCDI V3 | Tests that result in visual images requiring interpretation by a credentialed professional. |
Diagnostic Imaging Report | Interpreted results of imaging test that includes the study performed, reason, findings, and impressions. Includes both structured and unstructured (narrative) components. |
Swapna Abhyankar | Regenstrief Institute, LOINC Document Ontology Subcommittee | |||
| USCDI V3.1 | Patient Demographics/Information | Data used to categorize individuals for identification, records matching, and other purposes. |
Sex |
Documentation of a specific instance of sex. |
Both values must be supported:
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| USCDI V3.1 | Goals | Desired state to be achieved by a patient. |
Patient Goals | Desired outcomes of patient's care. |
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| USCDI V3.1 | Health Insurance Information | Data related to an individual’s insurance coverage for health care. |
Coverage Type |
Category of health care payers. (e.g., Medicare, TRICARE, Commercial Managed Care - PPO) |
Joel Andress | Centers for Medicare and Medicaid Services (CMS) Center for Clinical Standards and Quality (CCSQ) | ||
| USCDI V3.1 | Patient Demographics/Information | Data used to categorize individuals for identification, records matching, and other purposes. |
Middle Name (Including middle initial) | |||||
| USCDI V3.1 | 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. |
Health Concerns |
Health-related issue or worry. (e.g., weight gain, cancer risk) |
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| USCDI V3.1 | Problems | Condition, diagnosis, or reason for seeking medical attention. |
Date of Resolution |
Date of subsiding or termination of a symptom, problem, or condition. |
Steven Lane | Sutter Health | ||
| USCDI V3.1 | Vital Signs | Physiologic measurements of a patient that indicate the status of the body’s life sustaining functions. |
Head Occipital-frontal Circumference Percentile (Birth - 36 Months) | Both standards are required
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| USCDI V3.1 | Patient Demographics/Information | Data used to categorize individuals for identification, records matching, and other purposes. |
Occupation Industry |
Type of business that compensates for work or assigns work to an unpaid worker or volunteer. (e.g., U.S. Army, cement manufacturing, children and youth services) |
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Nedra Garrett | CDC |