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 Notes | Narrative patient data relevant to the context identified by note types.
|
Emergency Department Note |
Narrative summary of care delivered in an emergency department. |
|
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 | Medications | Pharmacologic agents used in the diagnosis, cure, mitigation, treatment, or prevention of disease. |
Route of Administration |
Physiological administration path of a therapeutic agent into or onto a patient. Examples include but are not limited to oral, topical, and intravenous. |
|
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 | Allergies and Intolerances | Harmful or undesired physiological responses associated with exposure to a substance. |
Allergy Intolerance Criticality |
Estimate of the potential clinical harm, or seriousness, of a reaction to an identified substance. |
Sandi Mitchell | J P Systems, Inc. | ||
| Draft USCDI V7 | Adverse Events | Unintended effects associated with clinical interventions. |
Adverse Event Outcome |
Result or impact of an adverse event. Examples include but are not limited to hospitalized, recovered, recovered with sequelae, and death. |
Sandi Mitchell | J P Systems, Inc. | ||
| 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. |
Nutrition Assessment |
Assessment of a person’s dietary intake. |
Michelle Ashafa | Academy of Nutrition and Dietetics | ||
| Draft USCDI V7 | Immunizations | Record of vaccine administration. |
Immunization Lot Number |
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 | Laboratory | Analysis of clinical specimens to obtain information about the health of a patient. |
Specimen Collection Method |
Technique or procedure used to obtain a specimen. Examples include but are not limited to venipuncture, swab, biopsy, aspiration, and catheter collection. |
Sanjeev Tandon on behalf of CDC | CDC | ||
| Draft USCDI V7 | Patient Demographics/Information | Data used to categorize individuals for identification, records matching, and other purposes. |
Interpreter Needed |
Indication of whether a person needs language interpretation services. |
|
Scott Stare | CMS Office of Minority Health | |
| Draft USCDI V7 | Orders | 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. |
Laboratory Order |
Provider-authored request for the performance of a laboratory test. |
|
Joel Andress | Centers for Medicare and Medicaid Services (CMS) Center for Clinical Standards and Quality (CCSQ) | |
| Draft USCDI V7 | Orders | 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. |
Medication Order |
Provider-authored request for the dispensing of a therapeutic agent. |
|
Joel Andress | Centers for Medicare and Medicaid Services (CMS) Center for Clinical Standards and Quality (CCSQ) | |
| Draft USCDI V7 | Orders | 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. |
Diagnostic Imaging Order |
Provider-authored request for the performance of a diagnostic imaging study. |
|
Joel Andress | Centers for Medicare and Medicaid Services (CMS) Center for Clinical Standards and Quality (CCSQ) | |
| Draft USCDI V7 | Orders | 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. |
Procedure Order |
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 | Orders | 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. |
Clinical Test Order |
Provider-authored request for the performance of a non-laboratory or non-imaging test. |
|
Joel Andress | Centers for Medicare and Medicaid Services (CMS) Center for Clinical Standards and Quality (CCSQ) | |
| Draft USCDI V7 | Medical Devices | Instrument, machine, appliance, implant, software, or similar device intended to be used for a medical purpose. |
Unique Device Identifier (UDI) |
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). |
|
Marti Velezis | FDA/CDRH/Indira Konduri (FDA/CDRH/OPEQ/ORP/DRPIII) | |
| Draft USCDI V7 | Orders | 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. |
Medical Device Order |
Provider-authored request for medical devices. Examples include but are not limited to therapeutic footwear, insulin infusion pump, and continuous positive airway pressure (CPAP) machine. |
Grace Glennon, on behalf of NCQA | NCQA | ||
| Draft USCDI V7 | Orders | 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. |
Referral Order |
Provider-authored request to another provider, specialist, or organization for care services. Examples include but are not limited to referral orders to a wound care specialist and to a podiatrist. |
Grace Glennon, on behalf of NCQA | NCQA | ||
| Draft USCDI V7 | Orders | 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. |
Nutrition Order |
Provider-authored request for therapeutic diet, nutrition support, and nutrition to promote and maintain health. Examples include but are not limited to cardiac diet, Mediterranean diet, whole food diet, clear liquid diet, enteral nutrition, and nutritional supplement. |
Michelle Ashafa | Academy of Nutrition and Dietetics | ||
| Draft USCDI V7 | Patient Demographics/Information | Data used to categorize individuals for identification, records matching, and other purposes. |
Deceased Indicator |
Indicates if the person is deceased or not. |
Sarah Gaunt | The Association of Public Health Laboratories (APHL) | ||
| Draft USCDI V7 | Healthcare Information Attributes | Contextual information that provides supporting details for healthcare data. |
Diagnostic Report Date |
Date and time a report containing test results or clinical interpretation was made available to providers. |
Sarah Gaunt | The Association of Public Health Laboratories (APHL) | ||
| Draft USCDI V7 | Encounter Information | Information related to interactions between healthcare providers and a patient. |
Appointment |
A planned healthcare event for a future date/time. Usage note: Created, tracked and managed for planned participation. An appointment may be called a future encounter and may result in one or more Encounters. |
Philip Lieberman | Analog Informatics Corporation |