ONC defined a common Meaningful Use data set that facilitates reporting for all summary of care records, care transitions, discharges, and patient access, allowing for more advanced clinical processes.
It includes the following:
- Patient name
- Sex
- Date of birth
- Race
- Ethnicity
- Preferred language
- Care team member(s)
- Medication Allergies
- Medications
- Care plan field(s) should include goals and instructions
- Problems
- Laboratory test(s)
- Laboratory value(s)/result(s)
- Procedures
- Smoking status
- Vital signs
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