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 | Laboratory | Analysis of clinical specimens to obtain information about the health of a patient. |
Tests |
Analysis of specimens derived from humans which provide information for the diagnosis, prevention, treatment of disease, or assessment of health. |
|
|||
| USCDI V3.1 | Clinical Notes | Narrative patient data relevant to the context identified by note types.
|
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. |
|
|||
| 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 | Clinical Tests | Non-imaging and non-laboratory tests performed that result in structured or unstructured findings specific to the patient to facilitate the diagnosis and management of conditions. |
Clinical Test |
Non-imaging or non-laboratory test. |
|
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. |
First Name | |||||
| USCDI V3.1 | Medications | Pharmacologic agents used in the diagnosis, cure, mitigation, treatment, or prevention of disease. |
Fill Status |
State of a medication with regards to dispensing or other activity. (e.g., dispensed, partially dispensed, not dispensed) |
Robert C Dieterle | Submitted on behalf of the Da Vinci Project | ||
| USCDI V3.1 | Patient Demographics/Information | Data used to categorize individuals for identification, records matching, and other purposes. |
Date of Death |
Known or estimated year, month, and day of the patient's death. |
Jeff Lyall | Cigna | ||
| USCDI V3.1 | Vital Signs | Physiologic measurements of a patient that indicate the status of the body’s life sustaining functions. |
Inhaled Oxygen Concentration | Both standards are required
|
||||
| USCDI V3.1 | Medications | Pharmacologic agents used in the diagnosis, cure, mitigation, treatment, or prevention of disease. |
Medications |
Pharmacologic agent used in the diagnosis, cure, mitigation, treatment, or prevention of disease. |
Optional:
|
|||
| 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 | Encounter Information | Information related to interactions between healthcare providers and a patient. |
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 | Assessment and Plan of Treatment | Health professional’s conclusions and working assumptions that will guide treatment of the patient. |
Assessment and Plan of Treatment |
Health professional’s conclusions and working assumptions that will guide treatment of the patient. |
||||
| USCDI V3.1 | Patient Demographics/Information | Data used to categorize individuals for identification, records matching, and other purposes. |
Related Person's Name |
Name of a person with a legal or familial relationship to a patient. |
Nedra Garrett | Centers for Disease Control and Prevention | ||
| 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. |
|
|||
| 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. |
Functional Status |
Assessment of a patient’s capabilities, or their risks of development or worsening of a condition or problem. (e.g., fall risk, pressure ulcer risk, alcohol use) |
|
Holly Miller, MD | MedAllies | |
| USCDI V3.1 | Laboratory | Analysis of clinical specimens to obtain information about the health of a patient. |
Values/Results |
Documented findings of a tested specimen including structured and unstructured components. |
Both standards are required:
|
|||
| USCDI V3.1 | Medications | Pharmacologic agents used in the diagnosis, cure, mitigation, treatment, or prevention of disease. |
Dose Units of Measure |
Units of measure of a medication. (e.g., milligrams, milliliters) |
|
Maria Michaels | CDC | |
| USCDI V3.1 | Vital Signs | Physiologic measurements of a patient that indicate the status of the body’s life sustaining functions. |
Weight-for-length Percentile (Birth - 24 Months) | Both standards are required
|
||||
| USCDI V3.1 | Diagnostic Imaging | Tests that result in visual images requiring interpretation by a credentialed professional. |
Diagnostic Imaging Report |
Interpreted results of imaging tests. Includes structured and unstructured components. |
Swapna Abhyankar | Regenstrief Institute, LOINC Document Ontology Subcommittee | ||
| 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
|