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
USCDI V3.1 Provenance

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

Author Organization

Organization associated with author.

USCDI V3.1 Care Team Members

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

Care Team Member Telecom

Phone or email contact information for a care team member

  • 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 (incorporated by reference in § 170.299)
  • 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
Keith W. Boone Audacious Inquiry
USCDI V3.1 Clinical Notes

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. 
Consultation Note

Response to request from a clinician for an opinion, advice, or service from another clinician.

  • Logical Observation Identifiers Names and Codes (LOINC®) version 2.72
    • At minimum: Consult Note (LOINC® code 11488-4)
USCDI V3.1 Care Team Members

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

Care Team Member Identifier

Sequence of characters used to uniquely refer to a member of the care team. (e.g., National Provider Identifier (NPI), National Council of State Boards of Nursing Identifier (NCSBN ID))

Al Taylor ONC
USCDI V3.1 Health Insurance Information

Data related to an individual’s insurance coverage for healthcare.

Relationship to Subscriber

Relationship of a patient to the primary insured person.

Mark Roberts Leavitt Partners
USCDI V3.1 Problems

Condition, diagnosis, or reason for seeking medical attention.

SDOH Problems/Health Concerns

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 2022 Release
  • International Classification of Diseases ICD-10-CM 2022
Mark Savage for Gravity Project Gravity Project
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)

USCDI V3.1 Problems

Condition, diagnosis, or reason for seeking medical attention.

Problems

Condition, diagnosis, or reason for seeking medical attention.  

  • SNOMED International, Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT®) U.S. Edition, March 2022 Release
  • International Classification of Diseases ICD-10-CM 2022
USCDI V3.1 Patient Demographics/Information

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

Phone Number Type

Contact point when using a phone (e.g., home, work, mobile).

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

  • Logical Observation Identifiers Names and Codes (LOINC®) version 2.72
  • The Unified Code of Units for Measure, Revision 2.1
USCDI V3.1 Clinical Notes

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

Summary of a patient’s interval status during an encounter (e.g., hospitalization, outpatient visit, treatment with a post-acute care provider, or other healthcare encounter)

  • Logical Observation Identifiers Names and Codes (LOINC®) version 2.72
    • At minimum: Progress Note (LOINC® code 11506-3)
USCDI V3.1 Patient Demographics/Information

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

Tribal Affiliation

Tribe or band with which an individual associates.

Laura Conn
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:

  • SNOMED CT U.S. Edition: 248152002 (Female)
  • SNOMED CT U.S. Edition: 248153007 (Male)
USCDI V3.1 Care Team Members

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

Care Team Member Role

Responsibility of an individual within the care team. (e.g., primary care physician, caregiver)

Al Taylor ONC
USCDI V3.1 Procedures

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

Reason for Referral

Explanation or justification for a referral or consultation.

Adam Bazer, MPD Integrating the Healthcare Enterprise USA (IHE USA)
USCDI V3.1 Patient Demographics/Information

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

Name Suffix

Name component following family name that may be used to describe a person's position in a family.

USCDI V3.1 Goals

Desired state to be achieved by a patient.

SDOH Goals

Desired future states (e.g., food security) for an identified Social Determinants of Health-related health concern, condition, or diagnosis. (e.g., food insecurity)

  • SNOMED International, Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT®) U.S. Edition, March 2022 Release
  • Logical Observation Identifiers Names and Codes (LOINC®) version 2.72
Mark Savage for Gravity Project Gravity Project
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 Provenance

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

Author Time Stamp

Date and time of author action.

USCDI V3.1 Patient Demographics/Information

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 1.2 (July 2021)