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 |
|---|---|---|---|---|---|---|---|---|
| Draft USCDI V5 | 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 | |||
| 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. |
Functional Status |
Assessment of a person’s ability to perform activities of daily living and activities across other situations and settings. Examples include but are not limited to Functional Assessment Standardized Items (FASI) and Timed Up and Go (TUG). |
|
Holly Miller, MD | MedAllies | ||
| 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. |
Disability Status |
Assessment of a patient’s physical, cognitive, or psychiatric disabilities. Examples include but are not limited to American Community Survey, Veterans RAND Health Survey, and Patient-Reported Outcomes Measurement Information System (PROMIS). |
|
Grace Cordovano | Enlightening Results | ||
| Draft USCDI V5 | Pharmacologic agents used in the diagnosis, cure, mitigation, treatment, or prevention of disease. |
Directions for administering or taking a medication. Usage note: May include route, quantity, timing/frequency, and special instructions (PRN, sliding scale, taper). Examples include but are not limited to prescription directions for taking a medication, and package instructions for over-the-counter medications. |
Shelly Spiro | Pharmacy HIT Collaborative | ||||
| Draft USCDI V5 | 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. Examples include but are not limited to U.S. Army, cement manufacturing, and children and youth services. |
|
Nedra Garrett | CDC | ||
| Draft USCDI V5 | Data used to categorize individuals for identification, records matching, and other purposes. |
Occupation | A self-reported term for the type of work done by a person. For a military position, this is the primary occupational specialty. |
|
Nedra Garrett | CDC | ||
| Draft USCDI V5 | Pharmacologic agents used in the diagnosis, cure, mitigation, treatment, or prevention of disease. |
Statement of whether a medication has been consumed according to instructions. Examples include but are not limited to taking as directed, taking less than directed, and not taking. |
|
Shelly Spiro | Pharmacy HIT Collaborative | |||
| Draft USCDI V5 | Data related to an individual’s insurance coverage for healthcare. |
Relationship to Subscriber |
Relationship of a patient to the primary insured person. |
Mark Roberts | Leavitt Partners | |||
| Draft USCDI V5 | Data related to an individual’s insurance coverage for healthcare. |
Coverage Status |
Presence or absence of health care insurance. |
Mark Roberts | Leavitt Partners | |||
| Draft USCDI V5 | Data used to categorize individuals for identification, records matching, and other purposes. |
Tribal Affiliation |
Tribe or band with which an individual associates. |
Laura Conn | ||||
| Draft USCDI V5 | Analysis of clinical specimens to obtain information about the health of a patient. |
Categorical assessment of a laboratory value, often in relation to a test's reference range. Examples include but are not limited to high, low, critical high, and normal. |
|
Riki Merrick | Association of Public Health Laboratories | |||
| Draft USCDI V5 | Analysis of clinical specimens to obtain information about the health of a patient. |
Specimen Identifier |
Sequence of characters assigned by a laboratory for an individual specimen. Example includes but is not limited to accession number. |
Riki Merrick | Association of Public Health Laboratories | |||
| Draft USCDI V5 | Analysis of clinical specimens to obtain information about the health of a patient. |
Numeric or alphanumeric code representing a collection of materials necessary to perform diagnostic tests. |
|
Riki Merrick | Association of Public Health Laboratories | |||
| 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. |
Alcohol Use |
Evaluation of a patient's consumption of alcohol. Examples include but are not limited to history of alcohol use, alcohol use disorder identification test, and alcohol intake assessment. |
|
Clem McDonald | National Library of Medicine | ||
| Draft USCDI V5 | Data used to categorize individuals for identification, records matching, and other purposes. |
Name that should be used when addressing or referencing the patient. Usage note: This information should be provided by the patient. Example includes but is not limited to nickname. |
Robert McClure, MD | HL7 International | ||||
| Draft USCDI V5 | Data used to categorize individuals for identification, records matching, and other purposes. |
Word or words that can replace a person’s name when addressing or referring to a person. Usage note: This information should be provided by the patient. Examples include but are not limited to she, her, they, them, he, his. |
Robert McClure, MD | HL7 International | ||||
| Draft USCDI V5 | Findings or other clinical data collected about a patient during care. |
Category based upon clinical observations typically associated with the designation of male and female. |
Robert McClure, MD | HL7 International | ||||
| Draft USCDI V5 | Narrative patient data relevant to the context identified by note types.
|
Operative Note | Summary of a surgical procedure. Usage note: May include procedures performed, operative and anesthesia times, findings observed, fluids administered, specimens obtained, and complications identified. |
|
Leslie Kelly Hall | Engaging Patient Strategy | ||
| Draft USCDI V5 | Findings or other clinical data collected about a patient during care. |
Statement of presence and properties of patient or provider authored documents that record a patient’s goals, preferences and priorities should a patient be unable to communicate them to a provider. Usage note: May include whether a person has one or more advance directives, the type of advance directive, the location of the current source document, and whether it has been verified. Examples include but are not limited to indication that a living will is on file, reference to or location of durable medical power of attorney, and validating provider. |
Rachel Eager | New York eHealth Collaborative | ||||
| Draft USCDI V5 | Analysis of clinical specimens to obtain information about the health of a patient. |
Information regarding a specimen, including the container, that does not meet a laboratory’s criteria for acceptability. Usage note: This may include information about the contents of the container, the container, and the label. Examples include but are not limited to hemolyzed, clotted, container leaking, and missing patient name. |
|
Han Tran | College of American Pathologists (CAP) |