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Patient Care Work GroupMaturity Level: 2 Trial Use Compartments: Patient

Detailed Descriptions for the elements in the Goal resource.

Goal
Element IdGoal
Definition

Describes the intended objective(s) for a patient, group or organization care, for example, weight loss, restoring an activity of daily living, obtaining herd immunity via immunization, meeting a process improvement objective, etc.

Control1..1
TypeDomainResource
Comments

Goal can be achieving a particular change or merely maintaining a current state or even slowing a decline.

Goal.identifier
Element IdGoal.identifier
Definition

Business identifiers assigned to this goal by the performer or other systems which remain constant as the resource is updated and propagates from server to server.

NoteThis is a business identifer, not a resource identifier (see discussion)
Control0..*
TypeIdentifier
Requirements

Allows identification of the goal as it is known by various participating systems and in a way that remains consistent across servers.

Comments

This is a business identifier, not a resource identifier (see discussion). It is best practice for the identifier to only appear on a single resource instance, however business practices may occasionally dictate that multiple resource instances with the same identifier can exist - possibly even with different resource types. For example, multiple Patient and a Person resource instance might share the same social insurance number.

Goal.status
Element IdGoal.status
Definition

Indicates whether the goal has been reached and is still considered relevant.

Control1..1
Terminology BindingGoalStatus (Required)
Typecode
Is Modifiertrue (Reason: This element is labelled as a modifier because it is a status element that contains status entered-in-error which means that the resource should not be treated as valid)
Requirements

Allows measuring outcome and whether goal needs to be further tracked.

Summarytrue
Comments

This element is labeled as a modifier because the status contains codes that mark the resource as not currently valid.

Goal.category
Element IdGoal.category
Definition

Indicates a category the goal falls within.

Control0..*
Terminology BindingGoal category (Example)
TypeCodeableConcept
Requirements

Allows goals to be filtered and sorted.

Summarytrue
Goal.priority
Element IdGoal.priority
Definition

Identifies the mutually agreed level of importance associated with reaching/sustaining the goal.

Control0..1
Terminology BindingGoal priority (Preferred)
TypeCodeableConcept
Requirements

Used for sorting and presenting goals.

Summarytrue
Comments

Extensions are available to track priorities as established by each participant (i.e. Priority from the patient's perspective, different practitioners' perspectives, family member's perspectives)

The ordinal extension on Coding can be used to convey a numerically comparable ranking to priority. (Keep in mind that different coding systems may use a "low value=important".

Goal.description
Element IdGoal.description
Definition

Human-readable and/or coded description of a specific desired objective of care, such as "control blood pressure" or "negotiate an obstacle course" or "dance with child at wedding".

Control1..1
Terminology BindingSNOMED CT Clinical Findings (Example)
TypeCodeableConcept
Requirements

Without a description of what's trying to be achieved, element has no purpose.

Summarytrue
Comments

If no code is available, use CodeableConcept.text.

Goal.subject
Element IdGoal.subject
Definition

Identifies the patient, group or organization for whom the goal is being established.

Control1..1
TypeReference(Patient | Group | Organization)
Requirements

Subject is optional to support annonymized reporting.

Summarytrue
Goal.start[x]
Element IdGoal.start[x]
Definition

The date or event after which the goal should begin being pursued.

Control0..1
Terminology BindingGoal start event (Example)
Typedate|CodeableConcept
[x] NoteSee Choice of Data Types for further information about how to use [x]
Requirements

Goals can be established prior to there being an intention to start pursuing them; e.g. Goals for post-surgical recovery established prior to surgery.

Summarytrue
Goal.target
Element IdGoal.target
Definition

Indicates what should be done by when.

Control0..1
Requirements

Allows the progress of the goal to be monitored against an observation or due date.

Invariants
Defined on this element
gol-1Rule Goal.target.measure is required if Goal.target.detail is populated(detail.exists() and measure.exists()) or detail.exists().not()
Affect this element
Goal.target.measure
Element IdGoal.target.measure
Definition

The parameter whose value is being tracked, e.g. body weight, blood pressure, or hemoglobin A1c level.

Control0..1
Terminology BindingLOINC Codes (Example)
TypeCodeableConcept
Summarytrue
Invariants
Affect this element
gol-1Rule Goal.target.measure is required if Goal.target.detail is populated(detail.exists() and measure.exists()) or detail.exists().not()
Goal.target.detail[x]
Element IdGoal.target.detail[x]
Definition

The target value of the focus to be achieved to signify the fulfillment of the goal, e.g. 150 pounds, 7.0%. Either the high or low or both values of the range can be specified. When a low value is missing, it indicates that the goal is achieved at any focus value at or below the high value. Similarly, if the high value is missing, it indicates that the goal is achieved at any focus value at or above the low value.

Control0..1
Terminology BindingGoalTargetDetail:
TypeQuantity|Range|CodeableConcept
[x] NoteSee Choice of Data Types for further information about how to use [x]
Summarytrue
Invariants
Affect this element
gol-1Rule Goal.target.measure is required if Goal.target.detail is populated(detail.exists() and measure.exists()) or detail.exists().not()
Goal.target.due[x]
Element IdGoal.target.due[x]
Definition

Indicates either the date or the duration after start by which the goal should be met.

Control0..1
Typedate|Duration
[x] NoteSee Choice of Data Types for further information about how to use [x]
Requirements

Identifies when the goal should be evaluated.

Summarytrue
Goal.statusDate
Element IdGoal.statusDate
Definition

Identifies when the current status. I.e. When initially created, when achieved, when cancelled, etc.

Control0..1
Typedate
Summarytrue
Comments

To see the date for past statuses, query history.

Goal.statusReason
Element IdGoal.statusReason
Definition

Captures the reason for the current status.

Control0..1
Typestring
Comments

This will typically be captured for statuses such as rejected, on-hold or cancelled, but could be present for others.

Goal.expressedBy
Element IdGoal.expressedBy
Definition

Indicates whose goal this is - patient goal, practitioner goal, etc.

Control0..1
TypeReference(Patient | Practitioner | RelatedPerson)
Summarytrue
Comments

This is the individual responsible for establishing the goal, not necessarily who recorded it. (For that, use the Provenance resource.).

Goal.addresses
Element IdGoal.addresses
Definition

The identified conditions and other health record elements that are intended to be addressed by the goal.

Control0..*
TypeReference(Condition | Observation | MedicationStatement | NutritionOrder | ServiceRequest | RiskAssessment)
Requirements

Allows specific goals to explicitly linked to the concerns they're dealing with - makes the goal more understandable.

Goal.note
Element IdGoal.note
Definition

Any comments related to the goal.

Control0..*
TypeAnnotation
Requirements

There's a need to capture information about the goal that doesn't actually describe the goal.

Comments

May be used for progress notes, concerns or other related information that doesn't actually describe the goal itself.

Goal.outcomeCode
Element IdGoal.outcomeCode
Definition

Identifies the change (or lack of change) at the point when the status of the goal is assessed.

Control0..*
Terminology BindingSNOMED CT Clinical Findings (Example)
TypeCodeableConcept
Requirements

Outcome tracking is a key aspect of care planning.

Comments

Note that this should not duplicate the goal status.

Goal.outcomeReference
Element IdGoal.outcomeReference
Definition

Details of what's changed (or not changed).

Control0..*
TypeReference(Observation)
Requirements

Outcome tracking is a key aspect of care planning.

Comments

The goal outcome is independent of the outcome of the related activities. For example, if the Goal is to achieve a target body weight of 150 lb and a care plan activity is defined to diet, then the care plan’s activity outcome could be calories consumed whereas goal outcome is an observation for the actual body weight measured.