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Responsibility of an individual within the care team. (e.g., primary care physician, caregiver)

Phone or email contact information for a care team member.

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

Place where a patient’s care is delivered.

Units of measure of a medication. (e.g., milligrams, milliliters)

• The Unified Code for Units of Measure, Revision 2.1

Sign, symptom, or medical condition that leads to the recommendation of a treatment, test, or procedure.

State of a medication with regards to dispensing or other activity. (e.g., dispensed, partially dispensed, not dispensed)

Assessment of a patient's level of cognitive functioning. (e.g., alertness, orientation, comprehension, concentration, and immediate memory for simple commands)

• Logical Observation Identifiers Names and Codes (LOINC®) version 2.72

State or condition of being pregnant or intent to become pregnant. (e.g., pregnant, not pregnant, intent to become pregnant, unknown)

Screening questionnaire-based, structured evaluation (e.g., PRAPARE, Hunger Vital Sign, AHC-HRSN screening tool) for a Social Determinants of Health related risk. (e.g., food insecurity, housing instability, or transportation insecurity)

• Logical Observation Identifiers Names and Codes (LOINC®) version 2.72

Optional: 

• SNOMED International, Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT®) U.S. Edition, March 2022 Release

Social Determinants of Health-related health concerns, conditions, or diagnoses. (e.g., homelessness, food insecurity)

• SNOMED International, Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT®) U.S. Edition, March 2022 Release
• International Classification of Diseases ICD-10-CM 2022

Desired future states (e.g., food security) for an identified Social Determinants of Health-related health concern, condition, or diagnosis. (e.g., food insecurity)

• SNOMED International, Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT®) U.S. Edition, March 2022 Release
• Logical Observation Identifiers Names and Codes (LOINC®) version 2.72

Actions or services to address an identified Social Determinants of Health-related health concern, condition, or diagnosis (e.g., education about food pantry program, referral to non-emergency medical transportation program)

• SNOMED International, Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT®) U.S. Edition, March 2022 Release
• Current Procedural Terminology (CPT®) 2022, 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

Sequence of characters used to uniquely refer to the individual that selects insurance benefits.

Sequence of characters used to uniquely refer to an insurance payer.

Category of health care payer. (e.g., Medicare, TRICARE, Commercial Managed Care - PPO)

Sequence of characters used to uniquely refer to a specific health insurance plan.

State or condition of a laboratory test.

Non-imaging or non-laboratory test.

• Logical Observation Identifiers Names and Codes (LOINC®) version 2.72

Tests that generate visual images (e.g., radiographic, photographic, video) and require interpretation by qualified professionals.

• Logical Observation Identifiers Names and Codes (LOINC®) version 2.72

Interpreted results of imaging tests. Includes structured and unstructured components.