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

Physiologic measurements of a patient that indicate the status of the body’s life sustaining functions.

Mean value of two or more blood pressure readings in a specified time period.

Usage note: Must include both systolic and diastolic components of the mean and specify the relevant time period of measurements.

Both standards are required.

  • Logical Observation Identifiers Names and Codes (LOINC®) version 2.73
  • The Unified Code of Units for Measure, Revision 2.1


 

 Matt Reid American Medical Association
Draft USCDI V4

Harmful or undesired physiological responses associated with exposure to a substance.

Non-pharmacologic agent believed to cause a harmful or undesired physiologic response following exposure.

Examples include but are not limited to latex, eggs, pollen, and peanuts.
  • Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT®) U.S. Edition, September 2022 Release
 John D'Amore Diameter Health
Draft USCDI V4

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

Time and/or date a procedure or other action is performed.

 Sheila Abner CDC/NHSN
Draft USCDI V4

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

Unit of measure of a medication.

Examples include but are not limited to milligram (mg) and milliliter (mL).
  • The Unified Code for Units of Measure, Revision 2.1
 Maria Michaels CDC
Draft USCDI V4

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

Sign, symptom, or medical condition that is the reason for giving or taking a medication.

 Maria Michaels CDC
Draft USCDI V4

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

State of a medication with regards to dispensing or other activity.

Examples include but are not limited to dispensed, partially dispensed, and not dispensed.

 Robert C Dieterle Submitted on behalf of the Da Vinci Project
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 or screening for the presence of a mental or behavioral problem.

Examples include but are not limited to alertness, orientation, comprehension, concentration, and immediate memory for simple commands.
  • Logical Observation Identifiers Names and Codes (LOINC®) version 2.73
 Michelle Dougherty Submitted on behalf of the CMS Data Element Library (DEL) Health IT Workgroup
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

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.

Screening questionnaire-based, structured evaluation for a Social Determinants of Health-related risk.

Examples include but are not limited to food, housing, and transportation security.
  • Logical Observation Identifiers Names and Codes (LOINC®) version 2.73
  • Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT®) U.S. Edition, September 2022 Release
 Mark Savage for Gravity Project Gravity Project
Draft USCDI V4

Condition, diagnosis, or reason for seeking medical attention.

Social Determinants of Health-related health concerns, conditions, or diagnoses.

Examples include but are not limited to homelessness, and food insecurity.
  • Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT®) U.S. Edition, September 2022 Release
  • International Classification of Diseases ICD-10-CM 2022
 Mark Savage for Gravity Project Gravity Project
Draft USCDI V4

Desired state to be achieved by a patient.

Desired future states for an identified Social Determinants of Health-related health concern, condition, or diagnosis.

Examples include but are not limited to food security, transportation security, and ability to access health care.
  • Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT®) U.S. Edition, September 2022 Release
  • Logical Observation Identifiers Names and Codes (LOINC®) version 2.73
 Mark Savage for Gravity Project Gravity Project
Draft USCDI V4

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

Actions or services to address an identified Social Determinants of Health-related health concern, condition, or diagnosis.

Examples include but are not limited to education about food pantry program, referral to non-emergency medical transportation program.
  • SNOMED International, Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT®) U.S. Edition, September 2022 Release
  • Current Procedural Terminology (CPT®) 2022, as maintained and distributed by the American Medical Association, for physician services and other health care services
  • Healthcare Common Procedure Coding System (HCPCS) Level II, as maintained and distributed by HHS
 Mark Savage for Gravity Project Gravity Project
Draft USCDI V4

Desired state to be achieved by a patient.

Person's goals, preferences, and priorities for care and treatment in case that person is unable to make medical decisions because of a serious illness or injury.

Examples include but are not limited to preferences regarding cardiopulmonary resuscitation, endotracheal intubation, and tube feeding.
  • Logical Observation Identifiers Names and Codes (LOINC®) version 2.73
 Matt Elrod on behalf of ADVault, Inc. ADVault, Inc.
Draft USCDI V4

Desired state to be achieved by a patient.

Person's goals, preferences, and priorities for overall experiences during their care and treatment.

Examples include but are not limited to honoring religious beliefs, and conditions of the care environment.
  • Logical Observation Identifiers Names and Codes (LOINC®) version 2.73
 Matt Elrod on behalf of ADVault, Inc. ADVault, Inc.
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.

Evaluation of a patient's reported use of drugs or other substances for non-medical purposes or in excess of a valid prescription.

Examples include but are not limited to substance use disorder score, and substance use knowledge assessment. 
  • Logical Observation Identifiers Names and Codes (LOINC®) version 2.73
 Jessica Cotto National Institute on Drug Abuse
Draft USCDI V4

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

Sequence of characters used to uniquely refer to the individual that selects insurance benefits.

 Robert C Dieterle On behalf of the Da Vinci Project
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

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

Categories of health care payers.

Examples include but are not limited to Medicare, Tricare, Commercial Preferred Provider Organization.

 Joel Andress Centers for Medicare and Medicaid Services (CMS) Center for Clinical Standards and Quality (CCSQ)
Draft USCDI V4

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

Sequence of characters used to uniquely refer to a specific health insurance plan.

 Robert C Dieterle On behalf of the Da Vinci Project
Draft USCDI V4

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

State or condition of a laboratory test.

 Maria Michaels CDC