USCDI+ BH Elements

US Behavioral Health Profiles Implementation Guide, published by . This guide is not an authorized publication; it is the continuous build for version 0.1.0 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/us-behavioral-health-profiles/ and changes regularly. See the Directory of published versions

The table provides a comprehensive list of the USCDI+ Behavioral Health elements used to model this implementation guide. The table includes various data classes such as adverse events, clinical notes, encounter information, health status assessments, and vital signs. Each data element includes specific descriptions that outline the type of data captured, its purpose, and examples where applicable, contributing to a structured approach to managing and sharing health information.

USCDI+ BH Data Class	USCDI+ BH Data Element	USCDI+ BH Data Element Description
Adverse Event	Adverse Event	An event that may be related to unintended effects on a patient or research participant.
Allergies and Intolerances	Reaction	Harmful or undesired physiologic response following exposure to a pharmacologic agent or class of agents.
Allergies and Intolerances	Substance (Medication)	Pharmacologic agent believed to cause a harmful or undesired physiologic response following exposure.
Allergies and Intolerances	Substance (Non-Medication)	Non-pharmacologic agent believed to cause a harmful or undesired physiologic response following exposure. Examples include but are not limited to latex, eggs, pollen, and peanuts.
Care Team Member(s)	Care Team Member Role	Responsibility of an individual within the care team. Examples include but are not limited to primary care physician and caregiver.
Care Team Member(s)	Care Team Member Telecom	Phone or email contact information for a care team member.
Care Team Member(s)	Care Team Member Identifier	Sequence of characters used to uniquely refer to a member of the care team. Examples include but are not limited to National Provider Identifier (NPI) and National Council of State Boards of Nursing Identifier (NCSBN ID).
Clinical Notes	Mental Health Consultation Note	Response to request from a mental health clinician for an opinion, advice, or service from another clinician.
Clinical Notes	Mental Health Discharge Summary Note	Synopsis of a patient’s admission and mental health course in a hospital or post-acute care setting. Usage note: Must contain admission and discharge dates and locations, discharge instructions, and reason(s) for hospitalization.
Clinical Notes	Mental Health History & Physical	Summary of current and past mental health conditions and observations used to inform an episode of care. Examples include but are not limited to admissions, surgeries, and other procedures.
Clinical Notes	Mental Health Procedure Note	Synopsis of non-operative mental health procedure.
Clinical Notes	Mental Health Progress Note	Summary of a patient’s mental health interval status during an encounter. Examples include but are not limited to hospitalization, outpatient visit, and treatment with a post-acute care provider, or other healthcare encounter.
Clinical Tests	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).
Clinical Tests	Clinical Test Result/Report	Findings of clinical tests.
Consent	Consent	Consent related to the release of information to non-HIPAA covered organizations
Diagnostic Imaging	Diagnostic Imaging Report	Interpreted results of imaging tests. Usage Note: Includes both structured and unstructured (narrative) components.
Diagnostic Imaging	Diagnostic Imaging Test	Tests that generate visual images and require interpretation by qualified professionals. Examples include but are not limited to radiographic, photographic, and video images.
Encounter Information	Diagnosis Rank	Ranking of the diagnosis relevent to the encounter
Encounter Information	Encounter Diagnosis	Coded diagnoses associated with an episode of care.
Encounter Information	Encounter Disposition	Place or setting to which the patient left a hospital or encounter.
Encounter Information	Encounter Location	Place where a patient’s care is delivered.
Encounter Information	Encounter Time	Date/times related to an encounter. Examples include but are not limited to scheduled appointment time, check in time, and start and stop times.
Encounter Information	Encounter Type	Category of health care service. Examples include but are not limited to office visit, telephone assessment, and home visit.
Facility Information	Facility Type	Category describing available services or resources. Examples include but are not limited to laboratory, pharmacy, hospital, ambulatory providers, long-term and post-acute care, and pharmacy.
Family Health History	Family Health History	Family Health History is an element of patient health data capturing relevant coded health data of a patient's family.
Federal/State Grants Reporting Requirements	Grant Number	A unique identifier for a grant.
Federal/State Grants Reporting Requirements	Grant Program ID	The grant program identifier provides more granular detail about the funded program.
Federal/State Grants Reporting Requirements	Grant/Funding Type	The specific program or project funded by a grant/fund.
Goals and Preferences	Care Experience Preference	Person's goals, preferences, and priorities for overall experiences during their care and treatment. Examples include but are not limited to religious beliefs, dislikes and fears, and thoughts and feelings to be shared.
Goals and Preferences	Patient Goals	Desired outcomes of patient’s care.
Goals and Preferences	SDOH Goals	Desired future states for an identified Social Determinants of Health-related health concern, condition, or diagnosis. Examples include but are not limited to food security, transportation security, and ability to access health care.
Goals and Preferences	Treatment Intervention Preference	Person's goals, preferences, and priorities for care and treatment in case that person is unable to make medical decisions because of a serious illness or injury.
Health Insurance Information	Plan Name	Name of the health plan benefit offering assigned to the Plan Identifier.
Health Insurance Information	Coverage Status	Presence or absence of health care insurance.
Health Insurance Information	Coverage Type	Category of health care payers, insurance products, or benefits. Examples include but are not limited to Medicaid, commercial, HMO, Medicare Part D, and dental.
Health Insurance Information	Group Identifier	Sequence of characters used to uniquely refer to a specific health insurance plan.
Health Insurance Information	Member Identifier	Sequence of characters used to uniquely refer to an individual with respect to their insurance.
Health Insurance Information	Payer Identifier	Sequence of characters used to uniquely refer to an insurance payer.
Health Insurance Information	Relationship to Subscriber	Relationship of a patient to the primary insured person.
Health Insurance Information	Subscriber Identifier	Sequence of characters used to uniquely refer to the individual that selects insurance benefits.
Health Status Assessments	Depression Assessment	Assessment or screening to determine the presence, severity, and impact of depressive symptoms on a patient’s mood, behavior, and overall quality of life. Examples include but are not limited to the Patient Health Questionnaire-9 (PHQ-9) for evaluating depression severity and the Beck Depression Inventory (BDI) for assessing depressive symptomatology.
Health Status Assessments	Mental/Cognitive Status	Assessment or screening for the presence of a mental or behavioral problem. Examples include but are not limited to alertness, orientation, comprehension, concentration, and immediate memory for simple commands.
Health Status Assessments	Anxiety Assesment	Assessment or screening to identify the presence, frequency, and severity of anxiety-related symptoms and their impact on daily functioning. Examples include but are not limited to the Generalized Anxiety Disorder 7-item (GAD-7) scale and the Beck Anxiety Inventory (BAI).
Health Status Assessments	Alcohol Use	Evaluation of a patient's consumption of alcohol. Examples include but are not limited to history of alcohol use, alcohol use disorder identification test and alcohol intake assessment.
Health Status Assessments	Disability Status	Assessments of a patient’s physical, cognitive, intellectual, or psychiatric disabilities. Examples include but are not limited to- vision, hearing, memory, and activities of daily living.
Health Status Assessments	Food Insecurity	Uncertain, limited, or unstable access to food that is: adequate in quantity and in nutritional quality; culturally acceptable; safe and acquired in socially acceptable ways.
Health Status Assessments	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 bathing, ambulation, and preparing a light meal.
Health Status Assessments	Housing Instability	Currently consistently housed but experiencing any of the following circumstances in the last 12 months: behind on rent or mortgage, 3 or more relocations, housing cost burden, homelessness, or risk of eviction.
Health Status Assessments	Pregnancy Status	State or condition of being pregnant or intent to become pregnant. Examples include but are not limited to pregnant, not pregnant, and unknown.
Health Status Assessments	SDOH Assessment	Screening questionnaire-based, structured evaluation for a Social Determinants of Health- related risk. Examples include but are not limited to food, housing, and transportation security.
Health Status Assessments	Smoking Status	Assessment of a patient’s smoking behaviors. Examples include but are not limited to pack- years and current use.
Health Status Assessments	Substance Use	Evaluation of a patient's reported use of drugs or other substances for non-medical purposes or in excess of a valid prescription. Examples include but are not limited to substance use disorder score, and substance use knowledge assessment.
Health Status Assessments	Transportation Insecurity	A condition in which one is regularly unable to move from place to place in a safe and timely manner because one lacks the material, economic or social resources necessary for transportation.
Health Status Assessments	Suicide Risk Assessment	An evaluation to identify individuals that require further suicide safety assessment.
Health Status Assessments	Interpersonal Violence	Violence between individuals, subdivided into family and intimate partner violence and community violence.
Health Status Assessments	Mental Health Status Screen	An evaluation of an individual's mental well-being to identify signs of potential mental health disorders that indicate a need for a more comprehensive assessment.
Health Status Assessments	Mental Trauma and PTSD Assessment	Evaluation of the presence of trauma history and the severity of PTSD symptoms.
Immunizations	Immunizations	Vaccine product administered, planned, or reported.
Laboratory	Tests	Analysis of specimens derived from humans which provide information for the diagnosis, prevention, treatment of disease, or assessment of health.
Laboratory	Values/Results	Documented findings of a tested specimen including structured and unstructured components.
Medications	Discharge Medications	Indication that a medication should be taken by or given to the patient after being discharged from an encounter.
Medications	Dose	Amount of a medication for each administration.
Medications	Dose Unit of Measure	Units of measure of a medication. Examples include but are not limited to milligram (mg) and milliliter (mL).
Medications	Medications	Pharmacologic agent used in the diagnosis, cure, mitigation, treatment, or prevention of disease.
Medications	Medication Adherence	Statement of whether a medication has been consumed according to instructions. Examples include but are not limited to taking as directed, taking less than directed, and not taking.
Medications	Medication Instructions	Directions for administering or taking a medication. Examples include but are not limited to prescription directions for taking a medication, and package instructions for over-the-counter medications. Usage notes: May include route, quantity, timing/frequency, and special instructions (PRN, sliding scale, taper).
Medications	Medication Quantity	The amount of medication, including the unit of measure, that is prescribed or dispensed.
Medications	Medications Dispensed	Description/ list of medications supplied to a patient with the intention that it is subsequently consumed by the patient.
Patient Demographics	Name to Use	Name that should be used when addressing or referencing a person.
Patient Demographics	Current Address	Place where a person is located or may be contacted. Includes street name, number, city/town, state, and zip code.
Patient Demographics	Date of Birth	Known or estimated year, month, and day of the patient's birth.
Patient Demographics	Email Address	Unique identifier of an individual's email account that is used to send and receive email messages.
Patient Demographics	Ethnicity	Patient's self-identification as Hispanic/ Latino or Non- Hispanic/ Non-Latino.
Patient Demographics	First Name	A personal name used before a family name.
Patient Demographics	Gender Identity	A person’s internal sense of being a man, woman, both, or neither.
Patient Demographics	Last Name	Portion of one's personal name indicating familial or communal ties.
Patient Demographics	Name Suffix	Name component following family name that may be used to describe a person's position in a family.
Patient Demographics	Phone Number	Numbers and symbols to contact an individual when using a phone.
Patient Demographics	Preferred Language	Documented language that the patient would like to use when discussing health care.
Patient Demographics	Race	An individual’s response to the race question based upon self-identification.
Patient Demographics	Related Person's Name	Name of a person with a legal or familial relationship to a patient.
Patient Demographics	Relationship Type	Relationship of a person to a patient. Examples include but are not limited to parent, next-of-kin, guardian, and custodian.
Patient Demographics	Sex	Documentation of a specific instance of sex and/or gender information.
Patient Demographics	Sexual Orientation	A person’s identification of their emotional, romantic, sexual, or affectional attraction to another person.
Patient Demographics	Tribal Affiliation	Tribe or band with which an individual associates.
Patient Demographics	Date of Death	Known or estimated year, month, and day of the patient's death.
Patient Demographics	Identifier	An identifier for the patient.
Patient Demographics	Pronouns	Words that can replace a person’s name when addressing or referring to a person
Patient Summary and Plan	Assessment and Plan of Treatment	Health professional’s conclusions and working assumptions that will guide treatment of the patient.
Problems	Problems/Conditions	Condition, diagnosis, or reason for seeking medical attention.
Problems	SDOH Problems/Health Concerns	Social Determinants of Health-related health concerns, conditions, or diagnoses. Examples include but are not limited to homelessness and food insecurity.
Problems	Date of Diagnosis	Date of first determination by a qualified professional of the presence of a problem or condition affecting a patient.
Problems	Date of Onset	Date when a problem/ condition started.
Problems	Date of Resolution	Date of subsiding or termination of a symptom, problem or condition.
Procedures	Harm Reduction Activities	Intervention tools or resources given to a patient to reduce harm, prevent overdose, and connect to health/social services. Examples include naloxone distribution, syringe services, and education on healthcare, treatment, and support services.
Procedures	Performance Time	Time and/or date a procedure is performed
Procedures	Procedures	Activity performed for or on a patient as part of the provision of care.
Procedures	Reason for Referral	Explanation or justification for a referral or consultation.
Procedures	SDOH Interventions	Actions or services to address an identified Social Determinants of Health-related health concern, condition, or diagnosis. Examples include but are not limited to education about food pantry program and referral to non- emergency medical transportation program.
Procedures	Peer Coaching or Mentoring	A one-on-one relationship in which a peer leader with more recovery experience than the person served encourages, motivates, and supports a peer who is seeking to establish or strengthen his or her recovery.
Procedures	Recovery Planning	A personalized client-centered approach to empower clients to take an active role on their journey towards recovery.
Vital Signs	Body Height	The vertical measurement of an individual's stature from the feet to the top of the head when standing upright.
Vital Signs	Body Temperature	Temperature is a measure of the patient's ability to generate and get rid of heat.
Vital Signs	Body Weight	The measurement of weight without heavy items located on the person.
Vital Signs	Diastolic Blood Pressure	Diastolic blood pressure, the bottom number, measures the force the heart exerts on the walls of the arteries in between beats.
Vital Signs	Heart Rate	Number of times the heart beats each minute.
Vital Signs	Pulse Oximetry	Pulse oximetry is a test used to measure the oxygen level (oxygen saturation) of the blood.
Vital Signs	Respiratory Rate	The respiration rate is the number of breaths a person takes per minute.
Vital Signs	Systolic Blood Pressure	Systolic blood pressure, the top number, measures the force the heart exerts on the walls of the arteries each time it beats.
Vital Signs	Average Blood Pressure	Arithmetic average of systolic and diastolic components of two of more blood pressure readings in a specified time period or according to a specified algorithm or protocol. Examples include but are not limited to 3-day morning and evening home monitoring, clinical encounter repeat average, and 24-hour ambulatory measurement.
Work Information	Farmworker Status	Data element capturing seasonal or migrant farm work status.
Work Information	Veteran Status	Military service in the armed forces of the United States or other nations, including the length and branch of service, the military occupation, the location and type of duty (e.g., in the United States or abroad with combat, combat support, or noncombat duties), and any ongoing illness, injury, limitation, or disability that began during military service (Institute of Medicine, Capturing Social and Behavioral Domains in Electronic Health Records, Phase 2, p. 297 (2014)).