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 | 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. |
Phone Number Type |
Contact point when using a phone (e.g., home, work, mobile). |
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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. |
Tests |
Analysis of specimens derived from humans which provide information for the diagnosis, prevention, treatment of disease, or assessment of health. |
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| USCDI V3.1 | Patient Demographics/Information | Data used to categorize individuals for identification, records matching, and other purposes. |
Last Name | |||||
| 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) |
|
Nedra Garrett | CDC | |
| 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 Result/Report |
Findings of clinical tests. |
Melissa Ayres | SSA | ||
| USCDI V3.1 | Vital Signs | Physiologic measurements of a patient that indicate the status of the body’s life sustaining functions. |
Pulse Oximetry | Both standards are required
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| 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. |
Pregnancy Status |
State or condition of being pregnant or intent to become pregnant. (e.g., pregnant, not pregnant, intent to become pregnant, unknown) |
Adam Bazer, MPD | Integrating the Healthcare Enterprise USA (IHE USA) | ||
| 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. |
Mental/Cognitive Status |
Assessment of a patient's level of cognitive functioning. (e.g., alertness, orientation, comprehension, concentration, and immediate memory for simple commands) |
|
Michelle Dougherty | Submitted on behalf of the CMS Data Element Library (DEL) Health IT Workgroup | |
| 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 | Patient Demographics/Information | Data used to categorize individuals for identification, records matching, and other purposes. |
Previous Name | |||||
| USCDI V3.1 | Patient Demographics/Information | Data used to categorize individuals for identification, records matching, and other purposes. |
Email Address |
Unique identifier of an individual's email account that is used to send and receive email messages. |
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| USCDI V3.1 | Patient Demographics/Information | Data used to categorize individuals for identification, records matching, and other purposes. |
Occupation |
Type of work of a person. (e.g., infantry, business analyst, social worker) |
|
Nedra Garrett | CDC | |
| USCDI V3.1 | Laboratory | Analysis of clinical specimens to obtain information about the health of a patient. |
Result Status |
State or condition of a laboratory test. |
Maria Michaels | CDC | ||
| Draft USCDI V4 | Tests that result in visual images requiring interpretation by a credentialed professional. |
Interpreted results of imaging tests. Usage Note: Includes both structured and unstructured (narrative) components. |
Swapna Abhyankar | Regenstrief Institute, LOINC Document Ontology Subcommittee | ||||
| Draft USCDI V4 | Information related to interactions between healthcare providers and a patient. |
Category of health care service. Examples include but are not limited to office visit, telephone assessment, and home visit. |
Joel Andress | Centers for Medicare and Medicaid Services (CMS) Center for Clinical Standards and Quality (CCSQ) | ||||
| Draft USCDI V4 | Physiologic measurements of a patient that indicate the status of the body’s life sustaining functions. |
Both standards are required
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| 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 | Information about a person who participates or is expected to participate in the care of a patient. |
Responsibility of an individual within the care team. Examples include but are not limited to primary care physician and caregiver. |
Al Taylor | ONC |