USCDI Export for the Public

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Classification Level Data Class Data Class Description Data Element Data Element Description Applicable Standards Submitter Name Submitter Organization Submission Date
Draft USCDI V4

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. 

Summary of a patient’s interval status during an encounter.

Examples include but are not limited to hospitalization, outpatient visit, and treatment with a post-acute care provider, or other healthcare encounter.
  • Logical Observation Identifiers Names and Codes (LOINC®) version 2.73
    • At minimum: Progress Note (LOINC code 11506-3)
Draft USCDI V4

Desired state to be achieved by a patient.

Desired outcomes of patient's care.
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.

Health-related issue or worry.

Examples include but are not limited to weight gain and cancer risk.
Draft USCDI V4

Record of vaccine administration.

Vaccine product administered, planned, or reported.

Both standards are required:

  • IIS: Current HL7 Standard Code Set, CVX –
    Vaccines Administered, updates through December 19, 2022
  • Vaccine National Drug Code (NDC) Directory – Vaccine
    NDC Linker Table, updates through December 20, 2022
Draft USCDI V4

Analysis of clinical specimens to obtain information about the health of a patient.

Analysis of specimens derived from humans which provide information for the diagnosis, prevention, treatment of disease, or assessment of health.
  • Logical Observation Identifiers Names and Codes (LOINC®) version 2.73
Draft USCDI V4

Analysis of clinical specimens to obtain information about the health of a patient.

Documented findings of a tested specimen including structured and unstructured components.
  • Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT®) U.S. Edition, September 2022 Release
Draft USCDI V4

Pharmacologic agents used in the diagnosis, cure, mitigation, treatment, or prevention of disease.

Pharmacologic agent used in the diagnosis, cure, mitigation, treatment, or prevention of disease.
  • RxNorm® Full Monthly Release January 3, 2023

Optional:

  • National Drug Code (NDC), January 6, 2023
Draft USCDI V4

Data used to categorize individuals for identification, records matching, and other purposes.
Draft USCDI V4

Data used to categorize individuals for identification, records matching, and other purposes.
Draft USCDI V4

Data used to categorize individuals for identification, records matching, and other purposes.
Draft USCDI V4

Data used to categorize individuals for identification, records matching, and other purposes.
Draft USCDI V4

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

Name component following family name that may be used to describe a person's position in a family.
Draft USCDI V4

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

Documentation of a specific instance of sex and/or gender information.

SNOMED International, Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT®) U.S. Edition, September 2022 Release
Draft USCDI V4

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

Known or estimated year, month, and day of the patient's birth.
Draft USCDI V4

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

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)
Draft USCDI V4

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

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)
Draft USCDI V4

Data used to categorize individuals for identification, records matching, and other purposes.
  • IETF (Internet Engineering Task Force) Request for Comment (RFC) 5646, “Tags for Identifying Languages”, September 2009

Adopted at 45 CFR 170.207(g)(2)
Draft USCDI V4

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

Place where a person is located or may be contacted
  • Project US@ Technical Specification for Patient Addresses, Final Version 1.0
Draft USCDI V4

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

Numbers and symbols to contact an individual when using a phone.

Both standards are required

  • 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, February 2001
  • 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, November 2010

Adopted at 45 CFR 170.207(q)(1)
Draft USCDI V4

Condition, diagnosis, or reason for seeking medical attention.

Condition, diagnosis, or reason for seeking medical attention.
  • Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT®) U.S. Edition, September 2022 Release
  • International Classification of Diseases ICD-10-CM 2022