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
USCDI V2 Procedures

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

 SDOH Interventions

A service offered to a patient to address identified Social Determinants of Health concerns, problems, or diagnoses (e.g., Education about Meals on Wheels Program, Referral to transportation support programs). SDOH data relate to conditions in which people live, learn, work, and play and their effects on health risks and outcomes.
  • SNOMED International, Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT®) U.S. Edition, March 2021 Release
  • Current Procedural Terminology (CPT®) 2021, 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
USCDI V2 Goals

Desired state to be achieved by a patient.

 SDOH Goals

Identifies a future desired condition or change in condition related to an SDOH risk in any domain and is established by the patient or provider. (e.g., Has adequate quality meals and snacks, Transportation security-able to access health and social needs). SDOH data relate to conditions in which people live, learn, work, and play and their effects on health risks and outcomes.
  • SNOMED International, Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT®) U.S. Edition, March 2021 Release
  • Logical Observation Identifiers Names and Codes (LOINC®) version 2.70
 Mark Savage for Gravity Project Gravity Project
USCDI V2 Allergies and Intolerances

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

 Substance (Drug Class)
  • SNOMED International, Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT®) U.S. Edition, March 2021 Release
USCDI V2 Patient Demographics/Information

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

 Date of Birth
USCDI V2 Problems

Condition, diagnosis, or reason for seeking medical attention.

 SDOH Problems/Health Concerns

An identified Social Determinants of Health-related condition (e.g., Homelessness (finding), Lack of adequate food Z59.41, Transport too expensive (finding)). SDOH data relate to conditions in which people live, learn, work, and play and their effects on health risks and outcomes.
  • ​​​​SNOMED International, Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT®) U.S. Edition, March 2021 Release
  • International Classification of Diseases ICD-10-CM 2021
 Mark Savage for Gravity Project Gravity Project
USCDI V2 Assessment and Plan of Treatment

Health professional’s conclusions and working assumptions that will guide treatment of the patient.

 SDOH Assessment

Structured evaluation of risk (e.g., PRAPARE, Hunger Vital Sign, AHC-HRSN screening tool) for any Social Determinants of Health domain such as food, housing, or transportation security. SDOH data relate to conditions in which people live, learn, work, and play and their effects on health risks and outcomes.
  • Logical Observation Identifiers Names and Codes (LOINC®) version 2.70
  • SNOMED International, Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT®) U.S. Edition, March 2021 Release
 Mark Savage for Gravity Project Gravity Project
USCDI V2 Patient Demographics/Information

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

 Previous Name
USCDI V2 Patient Demographics/Information

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

 Race

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 1.0 (March 2000)

Adopted at 45 CFR 170.207(f)
USCDI V2 Patient Demographics/Information

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

 Ethnicity

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 1.0 (March 2000)

Adopted at 45 CFR 170.207(f)
USCDI V2 Patient Demographics/Information

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

 Last Name
USCDI V2 Patient Demographics/Information

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

 Previous Address

Includes street name, number, city/town, state, and zip code.
USCDI V2 Allergies and Intolerances

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

 Substance (Medication)
  • RxNorm® Full Monthly Release, June 7, 2021
USCDI V2 Patient Demographics/Information

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

 Preferred Language

Request for Comment (RFC) 5646, “Tags for Identifying Languages”, September 2009

Adopted at 45 CFR 170.207(g)
USCDI V2 Patient Demographics/Information

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

 First Name
USCDI V2 Clinical Notes

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. 
 Consultation Note

Contains the response to request from a clinician for an opinion or advice from another clinician.

Logical Observation Identifiers Names and Codes (LOINC®) version 2.70

  • Consult Note (LOINC® code 11488-4)
USCDI V2 Patient Demographics/Information

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

 Current Address

Includes street name, number, city/town, state, and zip code.
USCDI V2 Patient Demographics/Information

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

 Phone Number

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)
USCDI V2 Problems

Condition, diagnosis, or reason for seeking medical attention.

 Problems
  • Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT®) U.S. Edition, March 2021 Release
  • International Classification of Diseases ICD-10-CM 2021
USCDI V2 Medications

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

 Medications
  • RxNorm® Full Monthly Release, June 7, 2021 
USCDI V2 Care Team Members

Information about a person who participates or is expected to participate in the care of a patient.

 Care Team Member Name Al Taylor ONC