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 | Information that guides treatment of the patient and recommendations for future treatment. |
Shared plan informed by members of a coordinated care team that details conditions, needs, and goals along with strategies for addressing them. Usage notes: Includes problems, health concerns, assessments, goals, and interventions from across care settings. Examples include but are not limited to clinical care plans, condition-specific care plans, coordinated care plan. |
Julia Skapik | NACHC | ||||
| Draft USCDI V7 | Analysis of clinical specimens to obtain information about the health of a patient. |
Information about a specimen, including the container, that is used to determine a laboratory’s criteria for acceptability. Usage note: This may include information about the contents of the container, the container, and the label. Examples include but are not limited to hemolyzed, clotted, container leaking, and missing patient name. |
|
Han Tran | College of American Pathologists (CAP) | |||
| Draft USCDI V7 | Analysis of clinical specimens to obtain information about the health of a patient. |
Upper and lower limit of quantitative test values expected for a designated population of individuals. Usage note: Reference range values may differ by patient characteristics, laboratory test manufacturer, and laboratory test performer. |
|
Nedra Y Garrett | CDC | |||
| Draft USCDI V7 | Analysis of clinical specimens to obtain information about the health of a patient. |
Unit of measurement to report quantitative results. |
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Nedra Y Garrett | CDC | |||
| Draft USCDI V7 | Tests that result in visual images requiring interpretation by a credentialed professional. |
The information that can be used to access a diagnostic imaging study. |
LOINC/RSNA Radiology Playbook includes Diagnostic Imaging Procedure Codes and Descriptions. HL7 Standard for CDA® Release 2: Imaging Integration; Basic Imaging Reports in CDA and DICOM Release 1 references LOINC® Document Type Codes, SNOMED CT® Quantity Measurement Type Codes, as well as DICOM Code Systems. FHIR ImagingStudy references SNOMED CT Body Structures |
Brian Bialecki | American College of Radiology | |||
| Draft USCDI V7 | Assessments of a health-related matter of interest, importance, or worry to a patient, patient’s family, or patient’s healthcare provider that could identify a need, problem, or condition. |
Evaluation of a patient's current or usual exercise. Examples include but are not limited to frequency of muscle-strengthening physical activity, days per week with moderate to strenuous physical activity, and minutes per day of moderate to strenuous physical activity. |
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Laurie P. Whitsel | American Heart Association/Physical Activity Alliance | |||
| Draft USCDI V7 | Narrative patient data relevant to the context identified by note types.
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Narrative summary of care delivered in an emergency department. |
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Smitha Vellanky, on behalf of Joel Andress and Centers for Medicare and Medicaid Services (CMS) Center for Clinical Standards and Quality (CCSQ) | On behalf of Centers for Medicare and Medicaid Services (CMS) Center for Clinical Standards and Quality (CCSQ) | |||
| Draft USCDI V7 | Pharmacologic agents used in the diagnosis, cure, mitigation, treatment, or prevention of disease. |
Physiological administration path of a therapeutic agent into or onto a patient. Examples include but are not limited to oral, topical, and intravenous. |
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Smitha Vellanky, on behalf of Joel Andress and Centers for Medicare and Medicaid Services (CMS) Center for Clinical Standards and Quality (CCSQ) | On behalf of Centers for Medicare and Medicaid Services (CMS) Center for Clinical Standards and Quality (CCSQ) | |||
| Draft USCDI V7 | Harmful or undesired physiological responses associated with exposure to a substance. |
Estimate of the potential clinical harm, or seriousness, of a reaction to an identified substance. |
HL7 FHIR R4 Allergy Intolerance Criticality, Rx Norm, SNOMED CT, National Drug Code (NDC) |
Sandi Mitchell | J P Systems, Inc. | |||
| Draft USCDI V7 | Unintended effects associated with clinical interventions. |
Result or impact of an adverse event. |
HL7.org FHIR R4 v4.0 |
Sandi Mitchell | J P Systems, Inc. | |||
| Draft USCDI V7 | Assessments of a health-related matter of interest, importance, or worry to a patient, patient’s family, or patient’s healthcare provider that could identify a need, problem, or condition. |
Assessment of a person’s dietary intake. |
LOINC 75304-6 Nutrition status observation panel |
Michelle Ashafa | Academy of Nutrition and Dietetics | |||
| Draft USCDI V7 | Record of vaccine administration. |
Sequence of characters representing a specific quantity of manufactured material within a batch of a vaccine product. |
Sandi Mitchell | J P Systems, Inc. | ||||
| Draft USCDI V7 | Analysis of clinical specimens to obtain information about the health of a patient. |
Technique or procedure used to obtain a specimen. |
SNOMED CT® |
Sanjeev Tandon on behalf of CDC | CDC | |||
| Draft USCDI V7 | Data used to categorize individuals for identification, records matching, and other purposes. |
Indication of whether a person needs language interpretation services. |
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Scott Stare | CMS Office of Minority Health | |||
| Draft USCDI V7 | Provider-authored request for the delivery of patient care services. Usage notes: Orders convey a provider’s intent to have a service performed on or for a patient, or to give instructions on future care. |
Provider-authored request for the performance of a laboratory test. |
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Joel Andress | Centers for Medicare and Medicaid Services (CMS) Center for Clinical Standards and Quality (CCSQ) | |||
| Draft USCDI V7 | Provider-authored request for the delivery of patient care services. Usage notes: Orders convey a provider’s intent to have a service performed on or for a patient, or to give instructions on future care. |
Provider-authored request for the dispensing of a therapeutic agent. |
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Joel Andress | Centers for Medicare and Medicaid Services (CMS) Center for Clinical Standards and Quality (CCSQ) | |||
| Draft USCDI V7 | Provider-authored request for the delivery of patient care services. Usage notes: Orders convey a provider’s intent to have a service performed on or for a patient, or to give instructions on future care. |
Provider-authored request for the performance of a diagnostic imaging study. |
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Joel Andress | Centers for Medicare and Medicaid Services (CMS) Center for Clinical Standards and Quality (CCSQ) | |||
| Draft USCDI V7 | Provider-authored request for the delivery of patient care services. Usage notes: Orders convey a provider’s intent to have a service performed on or for a patient, or to give instructions on future care. |
Provider-authored request for the performance of a diagnostic or therapeutic intervention. |
Joel Andress | Centers for Medicare and Medicaid Services (CMS) Center for Clinical Standards and Quality (CCSQ) | ||||
| Draft USCDI V7 | Provider-authored request for the delivery of patient care services. Usage notes: Orders convey a provider’s intent to have a service performed on or for a patient, or to give instructions on future care. |
Provider-authored request for the performance of a non-laboratory or non-imaging test. |
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Joel Andress | Centers for Medicare and Medicaid Services (CMS) Center for Clinical Standards and Quality (CCSQ) | |||
| Draft USCDI V7 | An instrument, machine, appliance, implant, software or other article intended to be used for a medical purpose. |
Numeric or alphanumeric code that uniquely identifies a medical device. Usage note: Contains a device identifier (DI) and may contain one or more production identifiers (PI). |
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Marti Velezis | FDA/CDRH/Indira Konduri (FDA/CDRH/OPEQ/ORP/DRPIII) |