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 |
|---|---|---|---|---|---|---|---|---|
| Draft USCDI V7 | Clinical Tests | Non-imaging and non-laboratory tests performed that result in structured or unstructured findings specific to the patient to facilitate the diagnosis and management of conditions. |
Clinical 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). |
|
Joel Andress | Centers for Medicare and Medicaid Services (CMS) Center for Clinical Standards and Quality (CCSQ) | |
| Draft USCDI V7 | Diagnostic Imaging | Tests that result in visual images requiring interpretation by a credentialed professional. |
Diagnostic Imaging Test |
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. |
|
Swapna Abhyankar | Regenstrief Institute, LOINC Document Ontology Subcommittee | |
| Draft USCDI V7 | Diagnostic Imaging | Tests that result in visual images requiring interpretation by a credentialed professional. |
Diagnostic Imaging Result/Report |
Interpreted results of imaging tests. Usage Note: Includes structured and unstructured (narrative) components. |
Swapna Abhyankar | Regenstrief Institute, LOINC Document Ontology Subcommittee | ||
| Draft USCDI V7 | Laboratory | Analysis of clinical specimens to obtain information about the health of a patient. |
Specimen Source Site |
Body location from where a specimen was obtained. Examples include but are not limited to right internal jugular, left arm, and right eye. |
|
Nedra Garrett | Centers for Disease Control and Prevention | |
| Draft USCDI V7 | Laboratory | Analysis of clinical specimens to obtain information about the health of a patient. |
Specimen Type |
Substance being sampled or tested. Examples include but are not limited to nasopharyngeal swab, whole blood, serum, urine, and wound swab. |
|
Nedra Garrett | Centers for Disease Control and Prevention | |
| Draft USCDI V7 | Problems | Condition, diagnosis, or reason for seeking medical attention. |
Condition Status |
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. |
Andre Quina | MITRE | ||
| Draft USCDI V7 | Procedures | Activity performed for or on a patient as part of the provision of care. |
Reason for Referral |
Explanation or justification for a referral or consultation. |
|
Adam Bazer, MPD | Integrating the Healthcare Enterprise USA (IHE USA) | |
| Draft USCDI V7 | Patient Demographics/Information | Data used to categorize individuals for identification, records matching, and other purposes. |
Relationship Type |
Relationship of a person to a patient. Examples include but are not limited to parent, next-of-kin, guardian, and custodian. |
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| Draft USCDI V7 | Patient Demographics/Information | Data used to categorize individuals for identification, records matching, and other purposes. |
Related Person's Name |
Name of a person with a legal or familial relationship to a patient. |
Nedra Garrett | Centers for Disease Control and Prevention | ||
| Draft USCDI V7 | Patient Demographics/Information | Data used to categorize individuals for identification, records matching, and other purposes. |
Patient Identifier |
Sequence of characters assigned by an organization to uniquely refer to a patient. Examples include but are not limited to Medical Record Number. |
Sarah Gaunt | Lantana Consulting Group | ||
| Draft USCDI V7 | Patient Demographics/Information | Data used to categorize individuals for identification, records matching, and other purposes. |
Date of Death |
Known or estimated year, month, and day of the patient’s death. |
Jeff Lyall | Cigna | ||
| Draft USCDI V7 | Health Insurance Information | Data related to an individual’s insurance coverage for healthcare. |
Health Insurance Payer |
Issuer of the policy. |
Shelly Spiro | Pharmacy HIT Collaborative | ||
| Draft USCDI V7 | Health Insurance Information | Data related to an individual’s insurance coverage for healthcare. |
Health Insurance Member Identifier |
Sequence of characters used to uniquely refer to an individual with respect to their insurance. |
Robert C Dieterle | On behalf of the Da Vinci Project | ||
| Draft USCDI V7 | Clinical Notes | Narrative patient data relevant to the context identified by note types.
|
Referral Note |
Narrative summary requesting an opinion, advice, or service from a clinician. Examples include but are not limited to primary care referral to dermatology, dentistry, and acupuncture. |
|
Swapna Abhyankar | Regenstrief Institute, LOINC Document Ontology Subcommittee | |
| Draft USCDI V7 | Clinical Tests | Non-imaging and non-laboratory tests performed that result in structured or unstructured findings specific to the patient to facilitate the diagnosis and management of conditions. |
Clinical Test Result/Report |
Findings of clinical tests. |
Melissa Ayres | SSA | ||
| Draft USCDI V7 | 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. |
Functional Status |
Assessment of a person’s ability to perform activities of daily living and activities across other situations and settings. Examples include but are not limited to Functional Assessment Standardized Items (FASI) and Timed Up and Go (TUG). |
|
Holly Miller, MD | MedAllies | |
| Draft USCDI V7 | Patient Demographics/Information | Data used to categorize individuals for identification, records matching, and other purposes. |
Accommodation |
Modifications, tools, technologies, and other supports necessary to access care. |
|
Grace Cordovano | Enlightening Results | |
| Draft USCDI V7 | 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. |
Disability Status |
Assessment of a patient’s physical, cognitive, or psychiatric disabilities. Examples include but are not limited to American Community Survey, Veterans RAND Health Survey, and Patient-Reported Outcomes Measurement Information System (PROMIS). |
|
Grace Cordovano | Enlightening Results | |
| Draft USCDI V7 | Medications | Pharmacologic agents used in the diagnosis, cure, mitigation, treatment, or prevention of disease. |
Medication Instructions |
Directions for administering or taking a medication. Usage note: May include route, quantity, timing/frequency, and special instructions (PRN, sliding scale, taper). Examples include but are not limited to prescription directions for taking a medication, and package instructions for over-the-counter medications. |
Shelly Spiro | Pharmacy HIT Collaborative | ||
| Draft USCDI V7 | Patient Demographics/Information | Data used to categorize individuals for identification, records matching, and other purposes. |
Occupation Industry |
Type of business that compensates for work or assigns work to an unpaid worker or volunteer. Examples include but are not limited to U.S. Army, cement manufacturing, and children and youth services. |
|
Nedra Garrett | CDC |