USCDI Export for the Public

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.

• Logical Observation Identifiers Names and Codes (LOINC®) version 2.80
  • At minimum: Progress note (LOINC code 11506-3)

Desired outcomes of patient’s care.

Examples include but are not limited to blood pressure control, functional ability, nutrition, and food security.

• Logical Observation Identifiers Names and Codes (LOINC)
• SNOMED Clinical Terms (SNOMED CT) U.S. Edition

Health-related issue or worry.

Examples include but are not limited to weight gain and cancer risk.

Vaccine product administered, planned, or reported.

Both standards are required:

• CVX – Vaccines Administered
• National Drug Code (NDC)

Analysis of specimens derived from humans which provide information for the diagnosis, prevention, treatment of disease, or assessment of health.

• Logical Observation Identifiers Names and Codes (LOINC®) 

Documented findings of a tested specimen including structured and unstructured components.

• SNOMED Clinical Terms (SNOMED CT®) U.S. Edition

Pharmacologic agent used in the diagnosis, cure, mitigation, treatment, or prevention of disease.

• RxNorm® 

Optional:

• National Drug Code (NDC)

Name component following family name that may be used to describe a person's position in a family.

Documentation of a specific instance of sex.

Both values must be supported: 

• SNOMED CT U.S. Edition: 248152002 (Female)
• SNOMED CT U.S. Edition: 248153007 (Male)

Known or estimated year, month, and day of the patient’s birth

Both standards are required

• The Office of Management and Budget Standards for Maintaining, Collecting, and Presenting Federal Data on Race and Ethnicity, Statistical Policy Directive No. 15
• CDC Race and Ethnicity Code Set

Both standards are required

• The Office of Management and Budget Standards for Maintaining, Collecting, and Presenting Federal Data on Race and Ethnicity, Statistical Policy Directive No. 15
• CDC Race and Ethnicity Code Set

• IETF (Internet Engineering Task Force) Request for Comment (RFC) 5646, “Tags for Identifying Languages”

Adopted at 45 CFR 170.207(g)(2)

Place where a person is located or may be contacted. 

Usage note: If the address pattern is not supported in the standard, implementations should align as closely as possible and avoid truncating any values. 

• Project US@ Technical Specification for Patient Addresses

Numbers and symbols to contact an individual when using a phone. 

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
• TU-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 Adopted at 45 CFR 170.207(q)(1) 

Condition, diagnosis, or reason for seeking medical attention.

Examples include but are not limited to diabetes, asthma, homelessness, food insecurity, and lead exposure.

• SNOMED Clinical Terms® (SNOMED CT®) U.S. Edition
• International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM)