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 |
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| Draft USCDI V5 | Analysis of clinical specimens to obtain information about the health of a patient. |
Upper and lower limit of quantitative test values expected for a designated population of individuals. Usage note: reference range values may differ by patient characteristics, laboratory test manufacturer, and laboratory test performer. |
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Nedra Y Garrett | CDC | |||
| Draft USCDI V5 | Analysis of clinical specimens to obtain information about the health of a patient. |
Unit of measurement to report quantitative laboratory test results. |
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Nedra Y Garrett | CDC | |||
| 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. |
Evaluation of a patient's current or usual exercise. Examples include but are not limited to frequency of muscle-strengthening physical activity, days per week with moderate to strenuous physical activity, and minutes per day of moderate to strenuous physical activity. |
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Laurie P. Whitsel | American Heart Association/Physical Activity Alliance | |||
| Draft USCDI V5 | Narrative patient data relevant to the context identified by note types.
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Emergency Department Note |
Summary of care delivered in an emergency department. |
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Smitha Vellanky, on behalf of Joel Andress and Centers for Medicare and Medicaid Services (CMS) Center for Clinical Standards and Quality (CCSQ) | On behalf of Centers for Medicare and Medicaid Services (CMS) Center for Clinical Standards and Quality (CCSQ) | ||
| Draft USCDI V5 | Pharmacologic agents used in the diagnosis, cure, mitigation, treatment, or prevention of disease. |
Physiological administration path of a therapeutic agent into or onto a patient. Examples include but are not limited to oral, topical, and intravenous. |
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Smitha Vellanky, on behalf of Joel Andress and Centers for Medicare and Medicaid Services (CMS) Center for Clinical Standards and Quality (CCSQ) | On behalf of Centers for Medicare and Medicaid Services (CMS) Center for Clinical Standards and Quality (CCSQ) | |||
| Draft USCDI V5 | Record of vaccine administration. |
Lot Number |
Sequence of characters representing a specific quantity of manufactured material within a batch. |
Sandi Mitchell | J P Systems, Inc. | |||
| Draft USCDI V5 | Data used to categorize individuals for identification, records matching, and other purposes. |
Interpreter Needed |
Indication of whether a person needs language interpretation services. |
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Scott Stare | CMS Office of Minority Health | ||
| USCDI V5 | Patient Summary and Plan | 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. |
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| USCDI V5 | Clinical Notes | Narrative patient data relevant to the context identified by note types.
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Consultation Note |
Narrative summary of care provided in response to a request from a clinician for an opinion, advice, or service. Examples include but are not limited to dermatology, dentistry, and acupuncture. |
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| USCDI V5 | Clinical Notes | Narrative patient data relevant to the context identified by note types.
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Discharge Summary Note |
Narrative 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. |
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| USCDI V5 | Clinical Notes | Narrative patient data relevant to the context identified by note types.
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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. |
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| USCDI V5 | Clinical Notes | Narrative patient data relevant to the context identified by note types.
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Procedure Note |
Narrative summary of non-operative procedure. Examples include but are not limited to interventional cardiology, gastrointestinal endoscopy, and osteopathic manipulation. |
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| USCDI V5 | Clinical Notes | Narrative patient data relevant to the context identified by note types.
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Progress Note |
Narrative 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. |
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| USCDI V5 | Goals and Preferences | Desired state to be achieved by a person or a person’s elections to guide care. |
Patient Goals |
Desired outcomes of patient’s care. |
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| USCDI V5 | Health Status Assessments | 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. |
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| USCDI V5 | Immunizations | Record of vaccine administration. |
Immunizations |
Vaccine product administered, planned, or reported. |
Both standards are required:
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| USCDI V5 | Laboratory | 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. |
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| USCDI V5 | Laboratory | 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. |
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| USCDI V5 | Medications | 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. |
Optional:
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| USCDI V5 | Patient Demographics/Information | Data used to categorize individuals for identification, records matching, and other purposes. |
First Name |