Care Team Member(s)The specific person(s) who participate or are expected to participate in the care team.
Clinical NotesComposed of both structured (i.e. obtained via pick-list and/or check the box) and unstructured (free text) data. A clinical note may include the history, Review of Systems (ROS), physical data, assessment, diagnosis, plan of care and evaluation of plan, patient teaching and other relevant data points.
GoalsAn expressed desired health state to be achieved by a subject of care (or family/group) over a period of time or at a specific point of time
Health ConcernsHealth related matter that is of interest, importance, or worry to someone who may be the patient, patients family or patients health care provider.
ImmunizationsRecord of an administration of a vaccination or a record of a vaccination as reported by a patient, a clinician, or another party.
ProblemsInformation about a condition, diagnosis, or other event, situation, issue, or clinical concept that is documented.
ProceduresAn activity that is performed with or on a patient as part of the provision of care.
ProvenanceThe metadata, or extra information about data, that can help answer questions such as when and who created the data.
Vital SignsPhysiologic measurements of a patient that indicate the status of the bodys life sustaining functions.
For data class description and applicable standards supporting data elements, click to view the USCDI Version 1 (July 2020 errata) in PDF format below.
The USCDI ONC New Data Element and Class (ONDEC) Submission System supports a predictable, transparent, and collaborative process, allowing health IT stakeholders to submit new data elements and classes for future versions of USCDI. Click here for more information and to submit new data elements.
The USCDI standard will follow the Standards Version Advancement Process described in the Cures rule to allow health IT developers to update their systems to newer version of USCDI and provide these updates to their customers.