USCDI Export for the Public

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.

Procedure Code (same as current USCDIv1): Health Care Financing Administration Common Procedure Coding System (HCPCS), as maintained and distributed by HHS. http://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets/index.html Current Procedural Terminology, Fourth Edition (CPT-4), as maintained and distributed by the American Medical Association, for physician services and other health care services. http://www.ama-assn.org/ama/pub/physician-resources/solutions-managing-your-practice/coding-billing-insurance/cpt.page SNOMED International, Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT®) U.S. Edition, September 2019 Release. http://www.nlm.nih.gov/research/umls/Snomed/snomed_main.html Optional: International Classification of Diseases ICD-10-PCS 2020. http://www.cms.gov/Medicare/Coding/ICD10/index.html Technology which records dental procedures: Code on Dental Procedures and Nomenclature (CDT), maintained and distributed by the American Dental Association, for dental services. http://www.ada.org/en/publications/cdt Procedure Date: HL7 FHIR Datatypes (dateTime|Period|string|Age|Range) http://hl7.org/fhir/datatypes.html#dateTime http://hl7.org/fhir/datatypes.html#Period http://hl7.org/fhir/datatypes.html#string http://hl7.org/fhir/datatypes.html#Age http://hl7.org/fhir/datatypes.html#Range Procedure Status: HL7 FHIR Event Status (preparation, in-progress, not-done, on-hold, stopped, completed, entered-in-error, unknown). http://hl7.org/fhir/R4/valueset-event-status.html

Units of measure of a medication. 

Examples include but are not limited to milligram (mg) and milliliter (mL).

• The Unified Code for Units of Measure (UCUM)

Sign, symptom, or medical condition that is the reason for a care activity.

Usage note: Indication may be included with a procedure, medication, and an order.

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

   

   

   

   

   

   

   

   

• International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM)

State of a medication with regards to dispensing or other activity. 

Examples include but are not limited to dispensed, partially dispensed, and not dispensed.

Assessment or screening for the presence of a mental or behavioral problem.

Examples include but are not limited to Confusion Assessment Method (CAM) and Patient Health Questionnaire (PHQ).

• Logical Observation Identifiers Names and Codes (LOINC®)

State or condition of being pregnant or intent to become pregnant.

Examples include but are not limited to pregnant, not pregnant, and unknown.

• Logical Observation Identifiers Names and Codes (LOINC)

Immunization event information source.
Examples include but are not limited to facility administering the immunization and an external record.

LOINC:30952-6- Date and time of vaccination: https://loinc.org/30952-6/ PHINVAD Immunization Information Source

State of an immunization event.

Immunization Code: CVX: Vaccines Administered 2.16.840.1.113762.1.4.1010.6: https://vsac.nlm.nih.gov/valueset/2.16.840.1.113762.1.4.1010.6/expansion Immunization Code: National Drug Codes (NDC): http://www2a.cdc.gov/vaccines/iis/iisstandards/ndc_tableaccess.asp Immunization Status: FHIR Immunization Status Codes: http://hl7.org/fhir/ValueSet/immunization-status Immunization Administered Date: FHIR datatypes: dateTime, String: https://www.hl7.org/fhir/us/core/StructureDefinition-us-core-immunization-definitions.html#Immunization.occurrence[x] Reason Immunization Not Performed: FHIR Immunization Status Reason Codes: http://hl7.org/fhir/R4/valueset-immunization-status-reason.html

Screening questionnaire-based, structured evaluation for a Social Determinants of Health-related risk.

Examples include but are not limited to food, housing, transportation security, and health literacy.

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

Person's goals, preferences, and priorities for care and treatment in case that person is unable to make medical decisions because of a serious illness or injury.

Examples include but are not limited to thoughts on cardiopulmonary resuscitation, mental health treatment preferences, and thoughts on pain management.

• Logical Observation Identifiers Names and Codes (LOINC®)

Person's goals, preferences, and priorities for overall experiences during their care and treatment.

Examples include but are not limited to religious beliefs, dislikes and fears, and thoughts and feelings to be shared.

• Logical Observation Identifiers Names and Codes (LOINC®)

Individual legally authorized to make healthcare decisions on behalf of a patient when the patient is unable to do so because of an illness or injury.