USCDI Export for the Public

Evaluation of a patient's reported use of drugs or other substances for non-medical purposes or in excess of a valid prescription.

Examples include but are not limited to substance use disorder score, and substance use knowledge assessment.

• Logical Observation Identifiers Names and Codes (LOINC®)

Function performed by the actor that participated in the creation or revision of data.

Usage note: The source of the information can be used to form assessments about its quality, reliability, trustworthiness, or can indicate where to go to determine the origins of the information.

Examples include but are not limited to provider, patient, family member, and device.

Sequence of characters used to uniquely refer to the individual that selects insurance benefits.

Sequence of characters used to uniquely refer to an insurance payer.

Category of healthcare payers, insurance products, or benefits. 

Examples include but are not limited to Medicaid, commercial, HMO, Veterans Benefits Administration, Medicare Part D, and dental.

• Source of Payment Typology (SOPT)

The time frame in which the policy is in force.

Member, subscriber, group, and plan identifiers are assigned by healthcare insurer. The coverage period is a standard date range during which the coverage is in effect. There is currently no standard Healthcare Payer Identifier (e.g. HPID) but frequently the NAIC identifier is used but not required.

Sequence of characters used to uniquely refer to a specific health insurance plan.

Kind of instrument, machine, appliance, implant, software, and similar medical device.

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

State or condition of a laboratory test.

Non-imaging or non-laboratory test.

Examples include but are not limited to electrocardiogram (ECG), visual acuity exam, macular exam, and graded exercise testing (GXT).

• Logical Observation Identifiers Names and Codes (LOINC®) version 2.80

Tests that generate visual images and require interpretation by qualified professionals.

Examples include but are not limited to computed tomography-head, radiograph-chest, and ultrasound-pelvis.

• Logical Observation Identifiers Names and Codes (LOINC®)

Interpreted results of imaging tests.

Usage Note: Includes structured and unstructured (narrative) components.

Body location from where a specimen was obtained. 

Examples include but are not limited to right internal jugular, left arm, and right eye.

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

Substance being sampled or tested. 

Examples include but are not limited to nasopharyngeal swab, whole blood, serum, urine, and wound swab.

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

Statement of how a diagnosis, problem, or condition presents or manifests in the patient.
Examples include but are not limited to active, resolved, recurrence, and remission.

HL7 FHIR Implementation Guide: minimal Common Oncology Data Elements (mCODE) Release 1 - US Realm | STU1

Explanation or justification for a referral or consultation. 

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

Relationship of a person to a patient. 

Examples include but are not limited to parent, next-of-kin, guardian, and custodian.

Name of a person with a legal or familial relationship to a patient.

Sequence of characters assigned by an organization to uniquely refer to a patient.
Examples include but are not limited to Medical Record Number.

FHIR US Core

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