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 V6 | Care Plans | Information that guides treatment of the patient and recommendations for future treatment. |
Shared plan informed by members of a coordinated care team that details conditions, needs, and goals along with strategies for addressing them. Usage notes: Includes problems, health concerns, assessments, goals, and interventions from across care settings. Examples include but are not limited to clinical care plans, condition-specific care plans, coordinated care plan. |
Julia Skapik | NACHC | |||
| USCDI V6 | Laboratory | Analysis of clinical specimens to obtain information about the health of a patient. |
Specimen Condition Acceptability |
Information about a specimen, including the container, that is used to determine 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) | |
| USCDI V6 | Laboratory | Analysis of clinical specimens to obtain information about the health of a patient. |
Result Reference Range |
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. |
|
Nedra Y Garrett | CDC | |
| USCDI V6 | Laboratory | Analysis of clinical specimens to obtain information about the health of a patient. |
Result Unit of Measure |
Unit of measurement to report quantitative laboratory test results. |
|
Nedra Y Garrett | CDC | |
| USCDI V6 | 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. |
Physical Activity |
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. |
|
Laurie P. Whitsel | American Heart Association/Physical Activity Alliance | |
| USCDI V6 | Clinical Notes | Narrative patient data relevant to the context identified by note types.
|
Narrative summary of care delivered in an emergency department. |
|
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) | ||
| USCDI V6 | Medications | Pharmacologic agents used in the diagnosis, cure, mitigation, treatment, or prevention of disease. |
Route of Administration |
Physiological administration path of a therapeutic agent into or onto a patient. Examples include but are not limited to oral, topical, and intravenous. |
|
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) | |
| USCDI V6 | Immunizations | Record of vaccine administration. |
Sequence of characters representing a specific quantity of manufactured material within a batch of a vaccine product. |
Sandi Mitchell | J P Systems, Inc. | |||
| USCDI V6 | Patient Demographics/Information | Data used to categorize individuals for identification, records matching, and other purposes. |
Indication of whether a person needs language interpretation services. |
|
Scott Stare | CMS Office of Minority Health | ||
| USCDI V6 | Orders | Provider-authored request for the delivery of patient care services. Usage notes: Orders convey a provider’s intent to have a service performed on or for a patient, or to give instructions on future care. |
Laboratory Order |
Provider-authored request for the performance of a laboratory test. |
|
Joel Andress | Centers for Medicare and Medicaid Services (CMS) Center for Clinical Standards and Quality (CCSQ) | |
| USCDI V6 | Orders | Provider-authored request for the delivery of patient care services. Usage notes: Orders convey a provider’s intent to have a service performed on or for a patient, or to give instructions on future care. |
Provider-authored request for the dispensing of a therapeutic agent. |
|
Joel Andress | Centers for Medicare and Medicaid Services (CMS) Center for Clinical Standards and Quality (CCSQ) | ||
| USCDI V6 | Orders | Provider-authored request for the delivery of patient care services. Usage notes: Orders convey a provider’s intent to have a service performed on or for a patient, or to give instructions on future care. |
Provider-authored request for the performance of a diagnostic imaging study. |
|
Joel Andress | Centers for Medicare and Medicaid Services (CMS) Center for Clinical Standards and Quality (CCSQ) | ||
| USCDI V6 | Orders | Provider-authored request for the delivery of patient care services. Usage notes: Orders convey a provider’s intent to have a service performed on or for a patient, or to give instructions on future care. |
Provider-authored request for the performance of a diagnostic or therapeutic intervention. |
Joel Andress | Centers for Medicare and Medicaid Services (CMS) Center for Clinical Standards and Quality (CCSQ) | |||
| USCDI V6 | Orders | Provider-authored request for the delivery of patient care services. Usage notes: Orders convey a provider’s intent to have a service performed on or for a patient, or to give instructions on future care. |
Provider-authored request for the performance of a non-laboratory or non-imaging test. |
|
Joel Andress | Centers for Medicare and Medicaid Services (CMS) Center for Clinical Standards and Quality (CCSQ) | ||
| USCDI V6 | Medical Devices | Instrument, machine, appliance, implant, software, or similar device intended to be used for a medical purpose. |
Numeric or alphanumeric code that uniquely identifies a medical device. Usage note: Contains a device identifier (DI) and may contain one or more production identifiers (PI). |
|
Marti Velezis | FDA/CDRH/Indira Konduri (FDA/CDRH/OPEQ/ORP/DRPIII) | ||
| Draft USCDI V7 | 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. |
||||||
| Draft USCDI V7 | Narrative patient data relevant to the context identified by note types.
|
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. |
|
|||||
| Draft USCDI V7 | Narrative patient data relevant to the context identified by note types.
|
Narrative summary of a patient’s admission and course in a hospital or post-acute care setting. Usage note: May 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. |
|
|||||
| Draft USCDI V7 | Narrative patient data relevant to the context identified by note types.
|
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. |
|
|||||
| Draft USCDI V7 | Narrative patient data relevant to the context identified by note types.
|
Narrative summary of non-operative procedure. Examples include but are not limited to interventional cardiology, gastrointestinal endoscopy, and osteopathic manipulation. |
|