Table 6

Medication Data Elements and Definitions

Element NameElement Definition
GP IIb/IIIa blocker
  • Indicate if a GP IIb/IIIa inhibitor was administered during the hospital stay. If yes, indicate which of the following:

  • • Eptifibatide

  • • Tirofiban

  • • Abciximab

GP IIb/IIIa blocker dosageIndicate the GP IIb/IIIa blocker dose given.
GP IIb/IIIa inhibitor administered start date/timeIndicate the date and time a GP IIb/IIIa inhibitor infusion was initiated during the hospital stay.
GP IIb/IIIa inhibitor administered stop date/timeIndicate the date and time the GP IIb/IIIa inhibitor infusion was permanently discontinued during the hospital stay.
GP IIb/IIIa inhibitor contraindicatedIndicate if a GP IIb/IIIa inhibitor was contraindicated during the hospital stay.
Anticoagulant (parenteral)
  • Indicate if an anticoagulant was administered during the hospital stay. If yes, indicate which of the following:

  • • IV unfractionated

  • • Low molecular weight

  • • Bivalirudin

  • • Fondaparinux

  • • Other

Anticoagulant doseIndicate the anticoagulant dose given.
Anticoagulant start date/timeIndicate the date and time an anticoagulant infusion was initiated during the hospital stay.
Anticoagulant stop date/timeIndicate the date and time an anticoagulant infusion was permanently discontinued during the hospital stay.
Anticoagulant contraindicatedIndicate if an anticoagulant agent was contraindicated during the hospital stay.
IV nitrateNitroglycerin was administered intravenously.
Oral or topical nitratesOral or topical nitroglycerin was administered. Commonly prescribed agents include isosorbide dinitrate, isosorbide mononitrate, transdermal infusion system, or nitroglycerin paste. Sublingual nitroglycerin or nitroglycerin spray used on an as-needed basis only should not be noted in this category.
IV beta blockerIndicate if IV beta blockers were administered. Some forms of IV beta blockers include atenolol, metoprolol, propranolol, timolol, esmolol, and labetalol.
Beta blocker before admissionIndicate if the patient has been taking a beta blocker routinely at home before this hospitalization. If yes, indicate which type.
Beta blocker in first 24 hIndicate if the beta blocker was administered in the first 24 h of care provided, regardless of location of care (e.g., transferring facility or EMS). If yes, indicate which type. Medications taken at home before hospital arrival and therefore not readministered until the next day of the hospitalization should be noted.
Beta-blocker contraindicationsIndicate if a beta blocker was not administered during the first 24 h of care because of a contraindication. A contraindication that is not documented explicitly by the healthcare provider but is evidenced clearly within the medical record should be noted.
Beta blocker (discharge)Indicate if a beta blocker was continued or prescribed at hospital discharge. Indicate which type and the dose prescribed.
Beta blocker (discharge) contraindicatedIndicate if a beta blocker was discontinued or not prescribed at discharge because of a contraindication. A contraindication that is not documented explicitly by the healthcare provider but is evidenced clearly within the medical record should be noted.
Calcium channel blockerIndicate if calcium channel blockers were administered. If yes, indicate which type. Some generic forms of calcium channel blockers are verapamil, nifedipine, diltiazem, nicardipine, nimodipine, nisoldipine, felodipine, and amlodipine.
Ranolazine before admissionIndicate if the patient has been taking ranolazine routinely at home before this hospitalization.
Ranolazine in first 24 hIndicate if ranolazine was administered in the first 24 h of care provided, regardless of location of care (e.g., transferring facility or EMS). Medications taken at home before hospital arrival and therefore not readministered until the next day of the hospitalization should be noted.
Ranolazine (discharge)Indicate if ranolazine was continued or prescribed at hospital discharge. Indicate which type and the dose prescribed.
Aspirin before admission
  • Indicate if the patient has been taking aspirin routinely at home before this hospitalization:

  • • 81 mg

  • • 162 mg

  • • 325 mg

  • • >325 mg

  • • Other

Aspirin in first 24 hIndicate if aspirin was administered in the first 24 h before or after hospital arrival, regardless of location of care (e.g., transferring facility or EMS). Medications taken at home before hospital arrival and therefore not readministered until the next day of the hospitalization should be noted.
Aspirin doseIndicate dose of aspirin given for the first 24 h.
Aspirin contraindicationsIndicate if aspirin was not administered during the first 24 h of care because of a contraindication. A contraindication that is not documented explicitly by the healthcare provider but is evidenced clearly within the medical record should be noted.
Aspirin (discharge)Indicate if aspirin was continued or prescribed at hospital discharge.
Aspirin (discharge) dose
  • Indicate the daily dose prescribed.

  • • 81 mg

  • • 162 mg

  • • 325 mg

  • • >325 mg

  • • Other

Aspirin (discharge) contraindicatedIndicate if aspirin was discontinued or not prescribed at discharge because of a contraindication. A contraindication that is not documented explicitly by the healthcare provider but is evidenced clearly within the medical record should be noted.
Other oral anticoagulants before admissionIndicate if the patient has been taking other oral anticoagulants (oral direct antithrombin inhibitor, e.g., dabigatran or oral direct factor Xa inhibitor, e.g., rivaroxaban, apixaban) routinely at home before this hospitalization.
Other oral anticoagulantIndicate if other oral anticoagulant was administered in the first 24 h of care provided, regardless of location of care (e.g., transferring facility or EMS). If yes, indicate which type. Medications taken at home before hospital arrival and therefore not readministered until the next day of the hospitalization should be noted.
Other oral anticoagulant (discharge)Indicate if other oral anticoagulant was continued or prescribed at hospital discharge. Indicate which type and the dose prescribed.
Warfarin before admissionIndicate if the patient has been taking warfarin routinely at home before this hospitalization.
WarfarinIndicate if warfarin was administered in the first 24 h of care provided, regardless of location of care (e.g., transferring facility or EMS). If yes, indicate which type. Medications taken at home before hospital arrival and therefore not readministered until the next day of the hospitalization should be noted.
Warfarin (discharge)Indicate if warfarin was continued or prescribed at hospital discharge. Indicate which type and the dose prescribed.
Warfarin or other oral anticoagulant (discharge contraindication)Indicate if warfarin was discontinued or not prescribed at discharge because of a contraindication. A contraindication that is not documented explicitly by the healthcare provider but is evidenced clearly within the medical record should be noted.
Clopidogrel before admissionIndicate if the patient has been taking clopidogrel routinely at home before this hospitalization.
Clopidogrel in first 24 hIndicate if clopidogrel was administered in the first 24 h of care provided, regardless of location of care (e.g., transferring facility or EMS). Medications taken at home before hospital arrival and therefore not readministered until the next day of the hospitalization should be noted.
Clopidogrel loading dose
  • Indicate the amount of the initial dose:

  • • 75 mg

  • • 150 mg

  • • 300 mg

  • • 600 mg

  • • Other

Clopidogrel start date/timeIndicate the date and time the initial dose was given.
Clopidogrel contraindicatedIndicate if clopidogrel was not administered during the first 24 h of care because of a contraindication. A contraindication that is not documented explicitly by the healthcare provider but is evidenced clearly within the medical record should be noted.
Clopidogrel (discharge)Indicate if clopidogrel was continued or prescribed at hospital discharge. Indicate which type and the dose prescribed.
Clopidogrel (discharge) contraindicatedIndicate if clopidogrel was discontinued or not prescribed at discharge because of a contraindication. A contraindication that is not documented explicitly by the healthcare provider but is evidenced clearly within the medical record should be noted.
Prasugrel before admissionIndicate if the patient has been taking prasugrel routinely at home before this hospitalization.
Prasugrel in first 24 hIndicate if prasugrel was administered in the first 24 h of care provided, regardless of location of care (e.g., transferring facility or EMS). Medications taken at home before hospital arrival and therefore not readministered until the next day of the hospitalization should be noted.
Prasugrel start date/timeIndicate the date and time the initial dose was given.
Prasugrel contraindicatedIndicate if prasugrel was not administered during the first 24 h of care because of a contraindication. A contraindication that is not documented explicitly by the healthcare provider but is evidenced clearly within the medical record should be noted.
Prasugrel (discharge)Indicate if prasugrel was continued or prescribed at hospital discharge. Indicate which type and the dose prescribed. DO NOT record discharge medication if patient was transferred to another acute care facility from your hospital.
Prasugrel (discharge) contraindicatedIndicate if prasugrel was discontinued or not prescribed at discharge because of a contraindication. A contraindication that is not documented explicitly by the healthcare provider but is evidenced clearly within the medical record should be noted.
Ticagrelor before admissionIndicate if the patient has been taking ticagrelor routinely at home before this hospitalization.
Ticagrelor in first 24 hIndicate if ticagrelor was administered in the first 24 h of care provided, regardless of location of care (e.g., transferring facility or EMS). Medications taken at home before hospital arrival and therefore not readministered until the next day of the hospitalization should be noted.
Ticagrelor start date/timeIndicate the date and time the initial dose was given.
Ticagrelor contraindicatedIndicate if ticagrelor was not administered during the first 24 h of care because of a contraindication. A contraindication that is not documented explicitly by the healthcare provider but is evidenced clearly within the medical record should be noted.
Ticagrelor (discharge)Indicate if ticagrelor was continued or prescribed at hospital discharge. Indicate which type and the dose prescribed. DO NOT record discharge medication if the patient was transferred to another acute care facility from your hospital.
Ticagrelor (discharge) contraindicatedIndicate if ticagrelor was discontinued or not prescribed at discharge because of a contraindication. A contraindication that is not documented explicitly by the healthcare provider but is evidenced clearly within the medical record should be noted.
Other oral antiplatelet medications before admissionIndicate if the patient has been taking other oral antiplatelet medications routinely at home before this hospitalization. These may include ticlopidine, dipyridamole, or cilostazol.
Other oral antiplatelet medications in first 24 hIndicate if other oral antiplatelets were administered in the first 24 h of care provided, regardless of location of care (e.g., transferring facility or EMS). Indicate which type and the dose administered. Medications taken at home before hospital arrival and therefore not readministered until the next day of the hospitalization should be noted.
Other oral antiplatelet medications (discharge)Indicate if other oral antiplatelet medications were continued or prescribed at hospital discharge. Indicate which type and the dose prescribed. DO NOT record discharge medication if the patient was transferred to another acute care facility from your hospital.
Other oral antiplatelet medications (discharge) contraindicatedIndicate if other oral antiplatelet medications were discontinued or not prescribed at discharge because of a contraindication. A contraindication that is not documented explicitly by the healthcare provider but is evidenced clearly within the medical record should be noted.
ACE inhibitor before admissionIndicate if the patient has been taking an ACE inhibitor routinely at home before this hospitalization.
ACE inhibitor in first 24 hIndicate if an ACE inhibitor was administered in the first 24 h of care provided, regardless of location of care (e.g., transferring facility or EMS). Medications taken at home before hospital arrival and therefore not readministered until the next day of the hospitalization should be noted.
ACE inhibitor contraindicatedIndicate if an ACE inhibitor was not administered during the first 24 h of care because of a contraindication. A contraindication that is not documented explicitly by the healthcare provider but is evidenced clearly within the medical record should be noted.
ACE inhibitor (discharge)Indicate if an ACE inhibitor was continued or prescribed at hospital discharge. Indicate which type and the dose prescribed. DO NOT record discharge medication if the patient was transferred to another acute care facility from your hospital.
ACE inhibitor (discharge) contraindicatedIndicate if an ACE inhibitor was discontinued or not prescribed at discharge because of a contraindication. A contraindication that is not documented explicitly by the healthcare provider but is evidenced clearly within the medical record should be noted.
ARB before admissionIndicate if the patient has been taking an ARB routinely at home before this hospitalization.
ARB in first 24 hIndicate if an ARB was administered in the first 24 h of care provided, regardless of location of care (e.g., transferring facility or EMS). Medications taken at home before hospital arrival and therefore not readministered until the next day of the hospitalization should be noted.
ARB contraindicatedIndicate if an ARB was not administered during the first 24 h of care because of a contraindication. A contraindication that is not documented explicitly by the healthcare provider but is evidenced clearly within the medical record should be noted.
ARB (discharge)Indicate if an ARB was continued or prescribed at hospital discharge. Indicate which type and the dose prescribed.
ARB (discharge) contraindicatedIndicate if an ARB was discontinued or not prescribed at discharge because of a contraindication. A contraindication that is not documented explicitly by the healthcare provider but is evidenced clearly within the medical record should be noted.
DiureticIndicate if a diuretic was continued or prescribed at hospital discharge. Aldosterone inhibitor is listed separately.
Aldosterone blocking agent (home)Indicate if the patient has been taking an aldosterone blocking agent routinely at home before this hospitalization.
Aldosterone blocking agent in first 24 hIndicate if an aldosterone blocking agent was administered in the first 24 h of care provided, regardless of location of care (e.g., transferring facility or EMS). Indicate which type and the dose administered. Medications taken at home before hospital arrival and therefore not readministered until the next day of the hospitalization should be noted.
Aldosterone blocking agent doseIndicate the aldosterone blocking agent dose given.
Aldosterone blocking agent (24 h) contraindicatedIndicate if an aldosterone blocking agent was not administered during the first 24 h of care because of a contraindication. A contraindication that is not documented explicitly by the healthcare provider but is evidenced clearly within the medical record should be noted.
Aldosterone blocking agent (discharge)Indicate if an aldosterone blocking agent was continued or prescribed at hospital discharge. Indicate which type and the dose prescribed. DO NOT record discharge medication if the patient was transferred to another acute care facility from your hospital.
Aldosterone blocking agent (discharge) contraindicatedIndicate if an aldosterone blocking agent was discontinued or not prescribed at discharge because of a contraindication. A contraindication that is not documented explicitly by the healthcare provider but is evidenced clearly within the medical record should be noted.
Statin before admissionIndicate if the patient has been taking a statin routinely at home before this hospitalization.
Statin in first 24 hIndicate if a statin was administered in the first 24 h of care provided, regardless of location of care (e.g., transferring facility or EMS). Indicate which type of statin was administered. Medications taken at home before hospital arrival and therefore not readministered until the next day of the hospitalization should be noted.
Statin dose
  • Indicate the following:

  • • Specific statin agent

  • • Statin dose given

Statin contraindicatedIndicate if statin was not administered during the first 24 h of care because of a contraindication. A contraindication that is not documented explicitly by the healthcare provider but is evidenced clearly within the medical record should be noted.
Statin (discharge)Indicate if a statin was continued or prescribed at hospital discharge. Indicate which type and the dose prescribed. DO NOT record discharge medication if the patient was transferred to another acute care facility from your hospital.
Statin (discharge) contraindicatedIndicate if statin medication was discontinued or not prescribed because of a contraindication. A contraindication that is not documented explicitly by the healthcare provider but is evidenced clearly within the medical record should be noted.
Other lipid-lowering agent (home)Indicate if the patient has been taking another lipid-lowering agent routinely at home before this hospitalization.
Other lipid-lowering agent (discharge)Indicate if another lipid-lowering agent was continued or prescribed at hospital discharge. Indicate which type and the dose prescribed.
Other lipid-lowering agent (discharge) contraindicatedIndicate if another lipid-lowering agent was discontinued or not prescribed at discharge because of a contraindication. A contraindication that is not documented explicitly by the healthcare provider but is evidenced clearly within the medical record should be noted.
Omega-3 fatty acid (discharge)Indicate if a preparation of omega-3 fatty acid supplement/medication was taken at discharge.
Antiarrhythmic (discharge)Indicate if an antiarrhythmic was administered.
AntidepressantsIndicate if the patient has been prescribed an antidepressant.
Female hormone replacement therapyIndicate if female hormone replacement therapy was administered.
Nicotine replacement and/or suppression therapyIndicate if nicotine replacement and/or suppression agents were administered (e.g., bupropion, varenicline).
NSAIDs
  • Indicate if the patient has been prescribed an NSAID. Indicate the type:

  • • Nonselective

  • • Cox-2 selective

InsulinIndicate if the patient has been prescribed insulin.
Oral hypoglycemic agent
  • Indicate if the patient has been prescribed an oral hypoglycemic agent for treatment of diabetes. Specify the agent:

  • • Sulfonylureas (e.g., tolbutamide, glipizide)

  • • Biguanides (e.g., metformin, buformin)

  • • Meglitinides (e.g., repaglinide, nateglinide)

  • • Thiazolidinediones (e.g., rosiglitazone, pioglitazone)

  • • Peptide analogs

  • • DPP-4 inhibitors (e.g., vildagliptin, sitagliptin)

  • • Alpha-glucosidase inhibitors (e.g., miglitol, acarbose)

  • • Experimental agents

Subcutaneous hypoglycemic agentIndicate if the patient has been prescribed a subcutaneous hypoglycemic agent for treatment of diabetes.
Influenza immunizationIndicate if the patient has received immunization for influenza or received one in the past 12 mo.
Pneumococcal immunizationIndicate if the patient has been immunized for pneumococcal pneumonia or received one in the past 12 mo.

ACE indicates angiotensin-converting enzyme; ARB, angiotensin receptor blocker; DPP, dipeptidyl peptidase; EMS, emergency medical services; GP, glycoprotein; IV, intravenous; and NSAID, nonsteroidal anti-inflammatory drug.