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Patient Care Work GroupMaturity Level: 2 Trial UseCompartments: Patient

Detailed Descriptions for the elements in the Goal resource.

Goal
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
Comments

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

Goal.identifier
Definition

This records identifiers associated with this care plan that are defined by business processes and/or used to refer to it when a direct URL reference to the resource itself is not appropriate (e.g. in CDA documents, or in written / printed documentation).

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

Need to allow connection to a wider workflow.

Goal.status
Definition

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

Control1..1
Terminology BindingGoalStatus (Required)
Typecode
Is Modifiertrue
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
Definition

Indicates a category the goal falls within.

Control0..*
Terminology BindingGoalCategory (Example)
TypeCodeableConcept
Requirements

Allows goals to be filtered and sorted.

Summarytrue
Goal.priority
Definition

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

Control0..1
Terminology BindingGoalPriority (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
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
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]
Definition

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

Control0..1
Terminology BindingGoalStartEvent (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
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.

InvariantsDefined on this element
gol-1: Goal.target.measure is required if Goal.target.detail is populated (expression : (detail.exists() and measure.exists()) or detail.exists().not(), xpath: (exists(f:*[starts-with(local-name(.), 'detail')]) and exists(f:measure)) or not(exists(f:*[starts-with(local-name(.), 'detail')])))
Affect this element
Goal.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
InvariantsAffect this element
gol-1: Goal.target.measure is required if Goal.target.detail is populated (expression : (detail.exists() and measure.exists()) or detail.exists().not(), xpath: (exists(f:*[starts-with(local-name(.), 'detail')]) and exists(f:measure)) or not(exists(f:*[starts-with(local-name(.), 'detail')])))
Goal.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
InvariantsAffect this element
gol-1: Goal.target.measure is required if Goal.target.detail is populated (expression : (detail.exists() and measure.exists()) or detail.exists().not(), xpath: (exists(f:*[starts-with(local-name(.), 'detail')]) and exists(f:measure)) or not(exists(f:*[starts-with(local-name(.), 'detail')])))
Goal.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
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
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
Definition

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

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

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

Goal.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
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
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
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.