Healthcare Data Elements

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National Syndromic Surveillance Program (NSSP) List of Healthcare Data Elements
State and Local Public Health Departments
Data Element Name

Data Element Description

Facility Identifier (Treating)

Unique facility identifier where the patient was treated (original provider of
the data)

Facility Name (Treating)

Name of the treating facility where the patient is treated

Treating Facility Address (Street address,
City, State, ZIP, and County)

Address of treating facility location:
Street Address, City, ZIP Code, County, State

Facility/Visit Type

Type of facility that the patient visited for treatment

Message (Event) Date / Time

Date and time that the report is created/generated from original source (from
treating facility)

Unique Physician Identifier
Provider Type
Unique Patient Identifier / Medical Record
Number

Unique identifier for the physician providing care
Type of provider
Unique identifier for the patient or visit

Unique Visit Identifier

Unique identifier for the visit/encounter

Age/Age Units

Numeric value of patient age at time of visit

Gender

Stated gender of patient

Race

Race of patient

Ethnicity

Ethnicity of patient

Patient City / Town

City or town of patient residence

Patient ZIP Code

ZIP Code of patient residence

Patient County

County of patient residence

Patient State

State of patient residence

Patient Country

Country of patient residence

Chief Complaint / Reason for Visit

Patient’s self-reported chief complaint or reason for visit

Admit or Encounter Reason

Short description of the provider’s reason for admitting the patient

Admit or Encounter Date / Time

Date and Time of encounter or admission

Date of Onset

Date that the patient began having symptoms of condition being reported

Patient Class

Patient classification within facility

Admission Type

This field indicates the circumstances under which the patient was or will be
admitted

Admit Source

This field indicates where the patient was admitted

Hospital Unit

Hospital unit where patient is at the time the message is sent (admission and
discharge)

Previous Hospital Unit

Hospital unit where patient was prior to the current transaction

Diagnosis Type

Qualifier for Diagnosis / Injury Code specifying type of diagnosis

Primary Diagnosis
Additional Diagnosis

Primary diagnosis of the patient’s condition
Additional diagnoses of the patient’s condition(s)

Discharge Disposition

Patient's anticipated location or status following discharge

Discharge or Disposition Date/Time

Date and time of discharge

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State and Local Public Health Departments - Continued
Data Element Name
Procedure Code

Data Element Description
Procedures administered to the patient

Triage Notes

Triage notes for the patient visit

Clinical Impression

Clinical impression (free text) of the diagnosis

Problem List

The problem list contains a narrative description of the conditions currently
being monitored for the patient

Problem List

Problem list of the patient condition(s)

Medication List
Medications Prescribed or Dispensed

Current medications entered as narrative
Current medications entered as standardized codes

Height

Height of the patient

Weight

Weight of the patient

BMI

Body Mass Index

Systolic and Diastolic Blood Pressure
(SBP/DBP) – Most recent

Most recent Systolic and Diastolic Blood Pressure of the patient

Initial Temperature

Initial temperature of the patient

Initial Pulse Oximetry

1st recorded pulse oximetry value

Smoking Status

Smoking status of patient

Initial Acuity

Assessment of the intensity of medical care the patient requires.

Insurance Coverage

Health insurance coverage of the patient

Travel History

Patient Travel History

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Department of Defense
Data Element Name

Data Element Description

Patient ZIP Code

The postal zip code for the city located. For outside contiguous United
States (OCONUS) location an APO/FPO (Military Post Office Zip Code) or
country zip code

Clinic ZIP Code

The Postal zip code for the city clinic is located. For OCONUS code is used
to correspond to obtained from CHCS (Composite Health Care System). Zip
code are indicative of OCONUS loc

Appointment Prefix

Designates whether the appointment is CHCS, Ambulatory Data System
(ADS), Clinical Integrated Workstation (CIW), CHCSII

Appointment Identifier Number

The appointment identifier number is a system generated unique app that
system. The appointment combine to create a unique identifier
Status of appointment record SADR extract. (Ready or Updated)

Appointment Standard Ambulatory
Data Record (SADR) Status
Appointment SADR Extract Date

Date the SADR was extracted

Appointment Status Type

Coded: appointment scheduled, walk-in, sick call, cancelled by provider,
telephone consult, no-show, cancelled by facility, or canceled by patient

CPT4 Version Year

Indicates the year of the most Current Procedural Terminology in ADM
(Ambulatory Data Module)

E&M code with Level “E”

Evaluation and Management appointment

CPT4 Codes with Diagnosis Flag

Field correlates CPT4 to diagnosis

Patient Age at Appointment

Age of patient at the day of the appointment. Age given in years

Disposition Code

Code that indicates circumstance under which patient leaves the facility.
(Code: released without limitations, released with work/duty restrictions, sick
at home/quarters, immediate referral, transferred to another facility, left
without being seen, left against medical advice, admitted, continued stay,
discharged home, or expired)

Administrative Disposition Code

Codes: Consultation requested, Referred to another provider, Convalescent
leave, Medical Board, or Medical hold

Treatment DMIS ID

The Defense Medical Information identification number that identifies patient
was treated

Gender

Code: Male or Female

Appointment (Encounter) Date

Date of the appointment

ICD-9 Version Year

Indicates the year of the most current ICD Code Table in ADM

ICD-9 Codes, Including Extenders

Four ICD-9 codes, 9 character level

Treatment MEPRS Code

Describes each work center

Patient Status

Code: inpatient or outpatient

Provider Specialty Code

Code that identifies the health providers medical specialty

End of Record Flag

End of record marker

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Department of Veterans Affairs
Data Element Name

Data Element Description

AnalysisVisitID

Created by BioSense to provide a consistent definition of a visit regardless of
how a visit is defined by a given hospital. Combines patient visits, if they occur within
24 hours of each other.

PatientID

Uniquely distinguishes a patient across all visits to a single facility or across all visits
to a healthcare system when a common patient identification system is used.

DateofVisit

Date of Visit based on the visit date associated with this specific clinical data, for this
specific Analysis Visit ID, in DATE format (mm/dd/yyyy).
Date and time of Visit based on the visit date associated with this specific
clinical data, for this specific Analysis Visit ID
Unique facility identifier of the facility where the patient originally presented
(original provider of the data)

AnalysisVisitDate
FacID
ServicingFacility

Primary VA Local Facility ID

PatientCounty

Patient county

PatientZip

Patient Zip code

Acuity

Age
AgeUnit
BirthDate

Indicates how quickly care is required. 30=“Time to evaluation or treatment
not critical ”; 20=”Request Prompt Evaluation or Treatment” “10=Request
Immediate Evaluation or Treatment”
Numeric value for patient age
Unit for numeric value (years, days, months)
Year and Month of patient birth

DeathDate

Date of death (mm/dd/yyyy)

Ethnicity

Patient ethnicity

Gender

Patient gender

Race

Patient race

Admit (1=Yes 0=No)

Numeric 1/0 indicator. Set to 1 if there is evidence of a hospital admission having
taken place

AdmitDate

Date of admission of patient into hospital (mm/dd/yyyy)

DeathCode

Hospital death disposition code that was reported

DischargeDate

Date patient was discharged from hospital

Disposition

Most recent non-Admit/Death Hospital Discharge Disposition Code (admit,
discharge, transfer, left, expiration)

BP

Max Blood Pressure associated with an Analysis Visit ID

MinBp

Min Blood Pressure associated with an Analysis Visit ID

Pulse

Max pulse oximetry associated with an Analysis Visit ID

MinPulse

Min pulse oximetry associated with an Analysis Visit ID

Temperature

Max temperature among recorded temperatures assoc w/ an Analysis Visit ID

MinTemperature

Min temperature among recorded temperatures assoc w/ an Analysis Visit ID

OnsetDate

Date the patient began having symptoms of condition

PatientClass

Emergency, outpatient, inpatient

ActivityCode

ICD-9-CM, ICD-19-CM, or SNOMED

Diagnosis / Injury Description OR
Chief Complaint/Reason for Visit

Text: description of activity code OR description of the reason the patient has
presented to the healthcare facility

Activity Status

Diagnosis type – admitting, working, final

Activity Type

Diagnosis/Injury Description, Chief Complaint, or Procedure

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Laboratory
Data Element Name

Data Element Description

BioSense Patient ID

Uniquely distinguishes a patient across all visits to a single facility or across all visits
to a healthcare system when a common patient identification system is used

BioSense Visit ID

Used to uniquely distinguish a patient visit based on the healthcare facility account
identifier. Created to reflect the visit as defined by the healthcare facility

Date of Birth
Sex

Patient date of birth (month/year)
Patient gender

Zip code

Patient or provider zip code

State

Patient or provider state

Ethnic group

Patient ethnicity

Race

Patient race

Date into Point of Care/location
Test Code / Name
Reason for Test
Specimen Type

Date patient arrived at healthcare facility
Local codes or local text names used to describe a laboratory test
ICD-9CM code
Type of sample taken for testing

Order Date/time

Date and time test was ordered

Ordering Facility Name

Name of facility that ordered test

Ordering Facility Address

Address of facility that ordered test

Ordering Facility Phone Number

Phone number of facility that ordered test

Ordering provider address

Address of healthcare provider that ordered test

Diagnostic Service

Type of diagnostic Service (immunology, microbiology…)

Performing laboratory

Lab within performing the service

Result Status

Final or pending

Report date/time

Date lab reports the result of the test

Collection date

Date sample was collected for test

Collection method

Method used to collect sample

Specimen site

From where on patient’s body the sample came

Accession date

Date the sample was received

Accession ID

Unique ID number assigned to sample when it is received by the laboratory

Sequence number

Number assigned to each lab order

Ordered Test Code/Name

LOINC codes and Descriptive text

Resulted Test Code/Name

LOINC or SNOMED codes and Descriptive text

Organism identified

Name of organism identified by a specific test

Method type

Ordered method for testing the specimen

Result other than organism

Result of a lab test that does not give the name of an organism

Result unit

Unit of measure for a lab test

Test Interpretation

Interpretation of the lab test result

Susceptibility test interpretation

Antimicrobials to which a microorganism is susceptible

Result notes

Important issues regarding the results

References Range

Range of what is normal or range of results that can be seen with that test

Last Update Date

Most recently updated date

Analysis Visit ID

Unique ID assigned for each visit

Lab Result Key ID

Unique ID for each patient

Coding Sys

Order or Result coding system (LOINC, SNOMED, NULL flavor)

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Pharmacy
Data Element Name

Data Element Description

RXNumber

Prescription number

QuantityDispensed

Total amount medication dispensed

DaysSupply
ProductName

Number of days worth of medication dispensed
Name of medication dispensed

GPICode

Generic Product Identifier number for medication

GPIText

Generic Product Identifier name for medication

RXNormCode

RXNORM number for medication

Pharmacy UID

Unique ID for Retail Pharmacy

Pharmacy5 digit zip
Age

Pharmacy Zip code (5 digits)
Patient age

PatZIP3

Patient Zip code (3 digits)

PatState

Patient State

PatCounty

Patient County

RecordUID

Record number

DateofService

DateRXTransactionatPharmacy

PrescriberIDQualifier

Prescriber type

PrescriberID

Unique ID number of prescribing healthcare provider

Insurance Type

Indicates Client type