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 V3 | Laboratory | Analysis of clinical specimens to obtain information about the health of a patient. |
Specimen Type |
Substance being sampled or tested. (e.g., nasopharyngeal swab, whole blood, serum, urine, wound swab). |
|
Nedra Garrett | Centers for Disease Control and Prevention | |
| USCDI V3 | Procedures | Activity performed for or on a patient as part of the provision of care. |
Reason for Referral |
Explanation or justification for a referral or consultation. |
Adam Bazer, MPD | Integrating the Healthcare Enterprise USA (IHE USA) | ||
| USCDI V3 | Patient Demographics/Information | Data used to categorize individuals for identification, records matching, and other purposes. |
Related Person's Relationship |
Relationship of a person to a patient. (e.g., parent, next-of-kin, guardian, custodian) |
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| USCDI V3 | Patient Demographics/Information | Data used to categorize individuals for identification, records matching, and other purposes. |
Related Person's Name |
Name of a person with a legal or familial relationship to a patient. |
Nedra Garrett | Centers for Disease Control and Prevention | ||
| USCDI V3 | Patient Demographics/Information | Data used to categorize individuals for identification, records matching, and other purposes. |
Date of Death | Known or estimated year, month, and day of the patient's death. |
Jeff Lyall | Cigna | ||
| USCDI V3 | Patient Demographics/Information | Data used to categorize individuals for identification, records matching, and other purposes. |
Gender Identity | A person’s internal sense of being a man, woman, both, or neither. |
Gender Identify must be coded in accordance with SNOMED CT® and HL7 Version 3 Standard, Value Sets for AdministrativeGender and NullFlavor, attributed as follows:
Adopted at 45 CFR 170.207(o)(2) |
A. Taylor | ONC | |
| USCDI V3 | Patient Demographics/Information | Data used to categorize individuals for identification, records matching, and other purposes. |
Sexual Orientation | A person’s identification of their emotional, romantic, sexual, or affectional attraction to another person |
|
A. Taylor | ONC | |
| USCDI V3 | Health Insurance Information | Data related to an individual’s insurance coverage for healthcare. |
Member Identifier |
Sequence of characters used to uniquely refer to an individual with respect to their insurance. |
Robert C Dieterle | On behalf of the Da Vinci Project | ||
| USCDI V3 | 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 |
Findings of clinical tests. |
Melissa Ayres | SSA | ||
| USCDI V3 | 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. |
Functional Status |
Assessment of a patient’s capabilities, or their risks of development or worsening of a condition or problem. (e.g., fall risk, pressure ulcer risk, alcohol use) |
|
Holly Miller, MD | MedAllies | |
| USCDI V3 | 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. |
Disability Status |
Assessments of a patient’s physical, cognitive, intellectual, or psychiatric disabilities. (e.g., vision, hearing, memory, activities of daily living) |
|
Grace Cordovano | Enlightening Results | |
| USCDI V3 | Patient Demographics/Information | 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. (e.g., U.S. Army, cement manufacturing, children and youth services) |
|
Nedra Garrett | CDC | |
| USCDI V3 | Patient Demographics/Information | Data used to categorize individuals for identification, records matching, and other purposes. |
Occupation |
Type of work of a person. (e.g., infantry, business analyst, social worker) |
|
Nedra Garrett | CDC | |
| USCDI V3 | Health Insurance Information | 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 | ||
| USCDI V3 | Health Insurance Information | Data related to an individual’s insurance coverage for healthcare. |
Coverage Status |
Presence or absence of health care insurance. |
Mark Roberts | Leavitt Partners | ||
| USCDI V3 | Patient Demographics/Information | Data used to categorize individuals for identification, records matching, and other purposes. |
Tribal Affiliation |
Tribe or band with which an individual associates. |
Laura Conn | |||
| USCDI V6 | Care Plans | Information that guides treatment of the patient and recommendations for future treatment. |
Health professional’s conclusions and working assumptions that will guide treatment of the patient. |
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| USCDI V6 | Clinical Notes | Narrative patient data relevant to the context identified by note types.
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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 V6 | Clinical Notes | Narrative patient data relevant to the context identified by note types.
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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 V6 | Clinical Notes | Narrative patient data relevant to the context identified by note types.
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History & Physical |
Narrative 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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