USCDI Export for the Public

Date/times related to an encounter. 

Examples include but are not limited to scheduled appointment time, check in time, and start and stop times.

Place or setting where the patient went after a hospital stay or encounter.

Coded diagnoses associated with an episode of care.

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

Explanation or justification provided when an order or practice guideline is not carried out. 

Usage note: Should be included with a procedure, immunization, and medication.

Amount of a medication for each administration.

Date of first determination by a qualified professional of the presence of a problem or condition affecting a patient.

Date or estimated date when signs or symptoms of a condition began.

Usage note: This may be a specific day, week, month, or year, or it may be an estimate.

Date of subsiding or termination of a symptom, problem, or condition.

Family member health condition(s) that are relevant to a patient's care.

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

Sequence of characters used to uniquely refer to a member of the care team.

Examples include but are not limited to National Provider Identifier (NPI) and National Council of State Boards of Nursing Identifier (NCSBN ID).

Place where care is delivered by a care team member.

Examples include but are not limited to clinic address and location description.

Responsibility of an individual within the care team.

Examples include but are not limited to primary care physician and caregiver.

Phone or email contact information for a care team member.

• 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 (incorporated by reference in § 170.299)
• 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

Place where a patient’s care is delivered.

• National Healthcare Safety Network (NHSN) Healthcare Facility Patient Care Location (HSLOC)
• SNOMED Clinical Terms® (SNOMED CT®) U.S. Edition

Sequence of characters by which an encounter is known. 

Arithmetic average of systolic and diastolic components of two of more blood pressure readings in a specified time period or according to a specified algorithm or protocol.

Examples include but are not limited to 3-day morning and evening home monitoring, clinical encounter repeat average, and 24-hour ambulatory measurement.

Both standards are required.

• Logical Observation Identifiers Names and Codes (LOINC®)
• The Unified Code of Units for Measure (UCUM)

Non-pharmacologic agent believed to cause a harmful or undesired physiologic response following exposure.

Examples include but are not limited to latex, eggs, pollen, and peanuts.

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

Time and/or date a care activity is performed.

Examples include but are not limited to vaccine and medication administration times, surgery start time, time ultrasound performed, and laboratory specimen collection time.

The status of planned or performed activity.

Examples include but are not limited to in-progress, completed, and not done.