Common Clinical Data Set
Common Clinical Data Set means the following data expressed, where indicated, according to the specified standard:
(1) Patient name. For certification to both the 2014 Edition EHR certification criteria and the 2015 Edition health IT certification criteria.
(2) Sex.
(i) No required standard for certification to the 2014 Edition EHR certification criteria.
(ii) The standard specified in § 170.207(n)(1) for certification to the 2015 Edition health IT certification criteria.
(3) Date of birth. For certification to both the 2014 Edition EHR certification criteria and the 2015 Edition health IT certification criteria.
(4) Race.
(i) The standard specified in § 170.207(f)(1) for certification to the 2014 Edition EHR certification criteria.
(ii) For certification to the 2015 Edition health IT certification criteria:
(A) The standard specified in § 170.207(f)(2);
(B) 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)(1) for certification to the 2014 Edition EHR certification criteria.
(ii) For certification to the 2015 Edition health IT certification criteria:
(A) The standard specified in § 170.207(f)(2);
(B) The standard specified in § 170.207(f)(1) for each ethnicity identified in accordance § 170.207(f)(2).
(6) Preferred language.
(i) The standard specified in § 170.207(g)(1) for certification to the 2014 Edition EHR certification criteria.
(ii) The standard specified in § 170.207(g)(2) for certification to the 2015 Edition Health IT certification criteria.
(7) Smoking status. For certification to both the 2014 Edition EHR certification criteria and the 2015 Edition health IT certification criteria: The standard specified in § 170.207(h).
(8) Problems.
(i) At a minimum, the standard specified in § 170.207(a)(3) for certification to the 2014 Edition EHR certification criteria.
(ii) At a minimum, the standard specified in § 170.207(a)(4) for certification to the 2015 Edition Health IT certification criteria.
(9) Medications.
(i) At a minimum, the standard specified in § 170.207(d)(2) for certification to the 2014 Edition EHR certification criteria.
(ii) At a minimum, the standard specified in § 170.207(d)(3) for certification to the 2015 Edition Health IT certification criteria.
(10) Medication allergies.
(i) At a minimum, the standard specified in § 170.207(d)(2) for certification to the 2014 Edition EHR certification criteria.
(ii) At a minimum, the standard specified in § 170.207(d)(3) for certification to the 2015 Edition Health IT certification criteria.
(11) Laboratory test(s).
(i) At a minimum, the standard specified in § 170.207(c)(2) for certification to the 2014 Edition EHR certification criteria.
(ii) At a minimum, the standard specified in § 170.207(c)(3) for certification to the 2015 Edition Health IT certification criteria.
(12) Laboratory value(s)/result(s). For certification to both the 2014 Edition EHR certification criteria and the 2015 Edition health IT certification criteria.
(13) Vital signs.
(i) Height/length, weight, blood pressure, and BMI for certification to the 2014 Edition EHR certification criteria.
(ii) For certification to the 2015 Edition Health IT certification criteria:
(A) 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
(B) 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).
(C) 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) Care plan field(s), including goals and instructions. For certification to the 2014 Edition EHR certification criteria.
(15) Procedures - (i)(A) At a minimum, the version of the standard specified in § 170.207(a)(3) for certification to the 2014 Edition EHR certification criteria and § 170.207(a)(4) for certification to the 2015 Edition health IT certification criteria, or § 170.207(b)(2); or
(B) For technology primarily developed to record dental procedures, the standard specified in § 170.207(b)(3) for certification to both the 2014 Edition EHR certification criteria and the 2015 Edition health IT certification criteria.
(ii) Optional. The standard specified in § 170.207(b)(4) for certification to both the 2014 Edition EHR certification criteria and the 2015 Edition health IT certification criteria.
(16) Care team member(s). For certification to both the 2014 Edition EHR certification criteria and the 2015 Edition health IT certification criteria.
(17) Immunizations. In accordance with, at a minimum, the standards specified in § 170.207(e)(3) and (4) for certification to the 2015 Edition health IT certification criteria.
(18) 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) for certification to the 2015 Edition health IT certification criteria.
(19) Assessment and plan of treatment. For certification to the 2015 Edition health IT certification criteria:
(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).
(20) Goals. In accordance with the “Goals Section” of the standard specified in § 170.205(a)(4) for certification to the 2015 Edition health IT certification criteria.
(21) Health concerns. In accordance with the “Health Concerns Section” of the standard specified in § 170.205(a)(4) for certification to the 2015 Edition health IT certification criteria.