Common Clinical Data Set

Common Clinical Data Set means the following data expressed, where indicated, according to the specified standard:
(1) Patient name.
(2) Sex: The standard specified in § 170.207(n)(1).
(3) Date of birth.
(4) Race:
(i) The standard specified in § 170.207(f)(2); and
(ii) The standard specified in § 170.207(f)(1) for each race identified in accordance § 170.207(f)(2).
(5) Ethnicity:
(i) The standard specified in § 170.207(f)(2); and
(ii) The standard specified in § 170.207(f)(1) for each ethnicity identified in accordance § 170.207(f)(2).
(6) Preferred language: The standard specified in § 170.207(g)(2).
(7) Smoking status.
(8) Problems: At a minimum, the standard specified in § 170.207(a)(4).
(9) Medications: At a minimum, the standard specified in § 170.207(d)(3).
(10) Medication allergies: At a minimum, the standard specified in § 170.207(d)(3).
(11) Laboratory test(s): At a minimum, the standard specified in § 170.207(c)(3).
(12) Laboratory value(s)/result(s).
(13) Vital signs:
(i) The patient's diastolic blood pressure, systolic blood pressure, body height, body weight, heart rate, respiratory rate, body temperature, pulse oximetry, and inhaled oxygen concentration must be exchanged in numerical values only; and
(ii) In accordance with the standard specified in § 170.207(c)(3) and with the associated applicable unit of measure for the vital sign measurement in the standard specified in § 170.207(m)(1).
(iii) Optional: The patient's BMI percentile per age and sex for youth 2-20 years of age, weight for age per length and sex for children less than 3 years of age, and head occipital-frontal circumference for children less than 3 years of age must be recorded in numerical values only in accordance with the standard specified in § 170.207(c)(3) and with the associated applicable unit of measure for the vital sign measurement in the standard specified in § 170.207(m)(1). For BMI percentile per age and sex for youth 2-20 years of age and weight for age per length and sex for children less than 3 years of age, the reference range/scale or growth curve should be included as appropriate.
(14) Procedures:
(i) At a minimum, the version of the standard specified in § 170.207(a)(4) or § 170.207(b)(2); or
(ii) For technology primarily developed to record dental procedures, the standard specified in § 170.207(b)(3).
(iii) Optional: The standard specified in § 170.207(b)(4).
(15) Care team member(s).
(16) Immunizations: In accordance with, at a minimum, the standards specified in § 170.207(e)(3) and (4).
(17) Unique device identifier(s) for a patient's implantable device(s): In accordance with the “Product Instance” in the “Procedure Activity Procedure Section” of the standard specified in § 170.205(a)(4).
(18) Assessment and plan of treatment:
(i) In accordance with the “Assessment and Plan Section (V2)” of the standard specified in § 170.205(a)(4); or
(ii) In accordance with the “Assessment Section (V2)” and “Plan of Treatment Section (V2)” of the standard specified in § 170.205(a)(4).
(19) Goals: In accordance with the “Goals Section” of the standard specified in § 170.205(a)(4).
(20) Health concerns: In accordance with the “Health Concerns Section” of the standard specified in § 170.205(a)(4).

Source

45 CFR § 170.102


Scoping language

For the purposes of this part:

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