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 |
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| USCDI V3.1 | Vital Signs | Physiologic measurements of a patient that indicate the status of the body’s life sustaining functions. |
BMI Percentile (2 - 20 years) | Both standards are required
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| USCDI V3.1 | Encounter Information | Information related to interactions between healthcare providers and patients. |
Encounter Diagnosis |
Coded diagnoses associated with an episode of care. |
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Joel Andress | Centers for Medicare and Medicaid Services (CMS) Center for Clinical Standards and Quality (CCSQ) | |
| USCDI V3.1 | Clinical Notes | Narrative patient data relevant to the context identified by note types.
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Consultation Note |
Response to request from a clinician for an opinion, advice, or service from another clinician. |
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| USCDI V3.1 | Problems | Condition, diagnosis, or reason for seeking medical attention. |
Date of Diagnosis | Date of first determination by a qualified professional of the presence of a problem or condition affecting a patient. |
Steven Lane | Sutter Health | ||
| USCDI V3.1 | Allergies and Intolerances | Harmful or undesired physiological responses associated with exposure to a substance. |
Reaction |
Harmful or undesired physiologic response following exposure to a pharmacologic agent or class of agents. |
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| 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. |
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| USCDI V3.1 | Patient Demographics/Information | Data used to categorize individuals for identification, records matching, and other purposes. |
Race | Both standards are required:
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| USCDI V3.1 | Clinical Notes | Narrative patient data relevant to the context identified by note types.
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Discharge Summary Note |
Synopsis of a patient’s admission and course in a hospital or post-acute care setting. Must contain admission and discharge dates and locations, discharge instructions, and reason(s) for hospitalization. |
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| USCDI V3.1 | Laboratory | Analysis of clinical specimens to obtain information about the health of a patient. |
Specimen Type |
Substance being sampled or tested. (e.g., nasopharyngeal swab, whole blood, serum, urine, wound swab). |
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Nedra Garrett | Centers for Disease Control and Prevention | |
| USCDI V3.1 | Encounter Information | Information related to interactions between healthcare providers and patients. |
Encounter Location |
Place where a patient’s care is delivered. |
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. |
Date of Birth |
Known or estimated year, month, and day of the patient's birth. |
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| USCDI V3.1 | Allergies and Intolerances | Harmful or undesired physiological responses associated with exposure to a substance. |
Substance (Drug Class) |
Pharmacologic category for an agent believed to cause a harmful or undesired physiologic response following exposure. |
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| 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 | Clinical Notes | Narrative patient data relevant to the context identified by note types.
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History & Physical |
Summary of current and past conditions and observations used to inform an episode of care. (e.g. admission, surgery, or other procedure) |
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| USCDI V3.1 | Clinical Notes | Narrative patient data relevant to the context identified by note types.
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Procedure Note |
Synopsis of non-operative procedures. (e.g., interventional cardiology, gastrointestinal endoscopy, osteopathic manipulation) |
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| USCDI V3.1 | Patient Demographics/Information | Data used to categorize individuals for identification, records matching, and other purposes. |
Previous Address |
Prior place where a person may have been located or could have been contacted. |
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| Draft USCDI V4 | 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. |
State or condition of being pregnant or intent to become pregnant. Examples include but are not limited to pregnant, not pregnant, and unknown. |
Adam Bazer, MPD | Integrating the Healthcare Enterprise USA (IHE USA) | ||||
| Draft USCDI V4 | Data related to an individual’s insurance coverage for healthcare. |
Sequence of characters used to uniquely refer to an insurance payer. |
Robert C Dieterle | On behalf of the Da Vinci Project | ||||
| Draft USCDI V4 | Harmful or undesired physiological responses associated with exposure to a substance. |
Harmful or undesired physiologic response following exposure to a pharmacologic agent or class of agents. |
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| Draft USCDI V4 | 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. |
Assessment of a patient’s capabilities, or their risks of development or worsening of a condition or problem. Examples include but are not limited to fall risk, and pressure ulcer risk. |
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Holly Miller, MD | MedAllies |