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 |
|---|---|---|---|---|---|---|---|---|
| USCDI V2 | Clinical Notes | Narrative patient data relevant to the context identified by note types.
|
Progress Note | Represents a patient’s interval status during a hospitalization, outpatient visit, treatment with a post-acute care provider, or other healthcare encounter. |
Logical Observation Identifiers Names and Codes (LOINC®) version 2.70
|
|||
| USCDI V2 | Problems | Condition, diagnosis, or reason for seeking medical attention. |
Date of Diagnosis | Date of first determination by a qualified professional of the presence of a problem or condition affecting a patient. |
Steven Lane | Sutter Health | ||
| USCDI V2 | Encounter Information | Information related to interactions between healthcare providers and a patient. |
Encounter Diagnosis |
|
Joel Andress | Centers for Medicare and Medicaid Services (CMS) Center for Clinical Standards and Quality (CCSQ) | ||
| USCDI V2 | Encounter Information | Information related to interactions between healthcare providers and a patient. |
Encounter Disposition | Identifies the location or type of facility to where the patient left following a hospital or encounter episode. |
Joel Andress | Centers for Medicare and Medicaid Services (CMS) Center for Clinical Standards and Quality (CCSQ) | ||
| USCDI V2 | Encounter Information | Information related to interactions between healthcare providers and a patient. |
Encounter Time |
Represents a date/time related to an encounter (e.g., scheduled appointment time, check in time, start and stop times). |
Joel Andress | Centers for Medicare and Medicaid Services (CMS) Center for Clinical Standards and Quality (CCSQ) | ||
| USCDI V2 | Immunizations | Record of vaccine administration. |
Immunizations |
|
||||
| USCDI V2 | Encounter Information | Information related to interactions between healthcare providers and a patient. |
Encounter Type | Joel Andress | Centers for Medicare and Medicaid Services (CMS) Center for Clinical Standards and Quality (CCSQ) | |||
| USCDI V2 | Patient Demographics/Information | Data used to categorize individuals for identification, records matching, and other purposes. |
Email Address | |||||
| USCDI V2 | Laboratory | Analysis of clinical specimens to obtain information about the health of a patient. |
Values/Results | Documented findings of the analysis of a tested specimen. Includes both structured and unstructured (narrative) components. |
||||
| USCDI V2 | Clinical Notes | Narrative patient data relevant to the context identified by note types.
|
Procedure Note | Encompasses non-operative procedures including interventional cardiology, gastrointestinal endoscopy, osteopathic manipulation, and other specialty’s procedures. |
Logical Observation Identifiers Names and Codes (LOINC®) version 2.70
|
|||
| USCDI V2 | Diagnostic Imaging | Tests that result in visual images requiring interpretation by a credentialed professional. |
Diagnostic Imaging Report | Interpreted results of imaging test that includes the study performed, reason, findings, and impressions. Includes both structured and unstructured (narrative) components. |
Swapna Abhyankar | Regenstrief Institute, LOINC Document Ontology Subcommittee | ||
| USCDI V2 | Allergies and Intolerances | Harmful or undesired physiological responses associated with exposure to a substance. |
Substance (Drug Class) |
|
||||
| USCDI V2 | Clinical Tests | 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 | Interpreted results of clinical tests that may include study performed, reason performed, findings, and impressions. Includes both structured and unstructured (narrative) components. |
Melissa Ayres | SSA | ||
| USCDI V2 | Allergies and Intolerances | Harmful or undesired physiological responses associated with exposure to a substance. |
Reaction |
|
||||
| USCDI V2 | Allergies and Intolerances | Harmful or undesired physiological responses associated with exposure to a substance. |
Substance (Medication) |
|
||||
| USCDI V2 | Diagnostic Imaging | Tests that result in visual images requiring interpretation by a credentialed professional. |
Diagnostic Imaging Test | The name of the test performed which generates visual images (radiographic, photographic, video, etc.) of anatomic structures; and requires interpretation by qualified professionals. |
|
Swapna Abhyankar | Regenstrief Institute, LOINC Document Ontology Subcommittee | |
| 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 | Clinical Tests | 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 | The name of the non-imaging or non-laboratory test performed on a patient. |
|
Joel Andress | Centers for Medicare and Medicaid Services (CMS) Center for Clinical Standards and Quality (CCSQ) | |
| USCDI V2 | Patient Demographics/Information | Data used to categorize individuals for identification, records matching, and other purposes. |
Phone Number Type | |||||
| USCDI V2 | Vital Signs | Physiologic measurements of a patient that indicate the status of the body’s life sustaining functions. |
Weight-for-length Percentile (Birth - 36 Months) |
|