USCDI Export for the Public

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Classification Level Sort descending	Data Class Description	Data Element	Data Element Description	Applicable Standards
Draft USCDI V5	Information that guides treatment of the patient and recommendations for future treatment.	Assessment and Plan of Treatment	Health professional’s conclusions and working assumptions that will guide treatment of the patient.
Draft USCDI V5	Narrative patient data relevant to the context identified by note types. 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	Response to request from a clinician for an opinion, advice, or service from another clinician. Examples include but are not limited to dermatology, dentistry, and acupuncture.	Logical Observation Identifiers Names and Codes (LOINC®) version 2.76 At minimum: Consult Note (LOINC code 11488-4)
Draft USCDI V5	Narrative patient data relevant to the context identified by note types. 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.	Discharge Summary Note	Summary of a patient’s admission and course in a hospital or post-acute care setting. Usage note: Must contain admission and discharge dates and locations, discharge instructions, and reason(s) for hospitalization. Examples include but are not limited to dermatology discharge summary, hematology discharge summary, and neurology discharge summary.	Logical Observation Identifiers Names and Codes (LOINC®) version 2.76 At minimum: Discharge Summary (LOINC code 18842-5)
Draft USCDI V5	Narrative patient data relevant to the context identified by note types. 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.	History & Physical	Summary of current and past conditions and observations used to inform an episode of care. Examples include but are not limited to admission, surgery, and other procedure.	Logical Observation Identifiers Names and Codes (LOINC®) version 2.76 At minimum: History and Physical Note (LOINC code 34117-2)
Draft USCDI V5	Narrative patient data relevant to the context identified by note types. 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.	Procedure Note	Summary of non-operative procedure. Examples include but are not limited to interventional cardiology, gastrointestinal endoscopy, and osteopathic manipulation.	Logical Observation Identifiers Names and Codes (LOINC®) version 2.76 At minimum: Procedure Note (LOINC code 28570-0)
Draft USCDI V5	Narrative patient data relevant to the context identified by note types. 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.	Progress Note	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 2.76 At minimum: Progress Note (LOINC code 11506-3)
Draft USCDI V5	Desired state to be achieved by a person or a person’s elections to guide care.	Patient Goals	Desired outcomes of patient’s care.
Draft USCDI V5	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 Concerns	Health-related issue or worry. Examples include but are not limited to weight gain and cancer risk.
Draft USCDI V5	Record of vaccine administration.	Immunizations	Vaccine product administered, planned, or reported.	Both standards are required: CVX – Vaccines Administered, updates through December 14, 2023 National Drug Code (NDC), updates through January 16, 2024
Draft USCDI V5	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.	Logical Observation Identifiers Names and Codes (LOINC®) version 2.76
Draft USCDI V5	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.	Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT®) U.S. Edition, September 2023 Release
Draft USCDI V5	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.	RxNorm® Full Monthly Release, January 2, 2024 Optional: National Drug Code (NDC), January 16, 2024
Draft USCDI V5	Data used to categorize individuals for identification, records matching, and other purposes.	First Name
Draft USCDI V5	Data used to categorize individuals for identification, records matching, and other purposes.	Last Name
Draft USCDI V5	Data used to categorize individuals for identification, records matching, and other purposes.	Previous Name
Draft USCDI V5	Data used to categorize individuals for identification, records matching, and other purposes.	Middle Name (Including middle initial)
Draft USCDI V5	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 V5	Data used to categorize individuals for identification, records matching, and other purposes.		Documentation of a specific instance of sex and/or gender information.	Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT®) U.S. Edition, September 2023 Release
Draft USCDI V5	Data used to categorize individuals for identification, records matching, and other purposes.	Date of Birth	Known or estimated year, month, and day of the patient's birth.
Draft USCDI V5	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 1.2 (July 2021)