PACIO Advance Directive Interoperability Implementation Guide
1.0.0 - STU 1 United States of America flag

PACIO Advance Directive Interoperability Implementation Guide, published by HL7 International / Patient Empowerment. This guide is not an authorized publication; it is the continuous build for version 1.0.0 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/fhir-pacio-adi/ and changes regularly. See the Directory of published versions

Resource Profile: ADI Personal Goal

Official URL: http://hl7.org/fhir/us/pacio-adi/StructureDefinition/ADI-PersonalGoal Version: 1.0.0
Active as of 2023-11-29 Computable Name: ADIPersonalGoal

This profile is a statement that presents the author’s personal health and treatment goals that are pertinent when planning their care.

The ADI Personal goal represents the patient’s personal goals and values related to quality of life that are intended to inform the treatment being provided. This may be communicated as a statement of what is important to the patient to have a good quality of life, such as avoiding prolonged dependence on machines or being able to feed, bathe, and take care of themselves. They may want to be to be able to die at home or not be a financial burden to their family. Content creators or implementers may provide a list of things the patient can select that are personally important to them or the decisions may be captured in narrative form. Without any more specificity than what the personal goal of the patient is, a medical team may be able to narrow down a list of potential treatment interventions to just a few whose outcomes would enable meeting the patient’s documented personal goals and values.

Usage:

Formal Views of Profile Content

Description of Profiles, Differentials, Snapshots and how the different presentations work.

This structure is derived from USCoreGoalProfile

NameFlagsCard.TypeDescription & Constraintsdoco
.. Goal C0..*USCoreGoalProfileDescribes the intended objective(s) for a patient, group or organization
goal-subject-expressedby: subject and expressedBy refer to the same patient
... text S1..1NarrativeText summary of the resource, for human interpretation
... Slices for category S1..*CodeableConceptE.g. Treatment, dietary, behavioral, etc.
Slice: Unordered, Open by value:$this
.... category:All Slices Content/Rules for all slices
..... text S0..1stringPlain text representation of the concept
.... category:type S1..1CodeableConceptE.g. Treatment, dietary, behavioral, etc.
Required Pattern: At least the following
..... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
...... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
...... code1..1codeSymbol in syntax defined by the system
Fixed Value: 87528-6
... description
.... EnclosedPreconditionExtension 0..1CodeableConceptEnclosed Precondition
URL: http://hl7.org/fhir/us/pacio-adi/StructureDefinition/adi-enclosedPrecondition-extension

doco Documentation for this format

Constraints

IdGradePath(s)DetailsRequirements
goal-subject-expressedbyerrorGoalsubject and expressedBy refer to the same patient
: subject = expressedBy
NameFlagsCard.TypeDescription & Constraintsdoco
.. Goal C0..*USCoreGoalProfileDescribes the intended objective(s) for a patient, group or organization
goal-subject-expressedby: subject and expressedBy refer to the same patient
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... text S1..1NarrativeText summary of the resource, for human interpretation
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... Slices for category SΣ1..*CodeableConceptE.g. Treatment, dietary, behavioral, etc.
Slice: Unordered, Open by value:$this
Binding: GoalCategory (example): Codes for grouping and sorting goals.


.... category:All Slices Content/Rules for all slices
..... text SΣ0..1stringPlain text representation of the concept
.... category:type SΣ1..1CodeableConceptE.g. Treatment, dietary, behavioral, etc.
Binding: GoalCategory (example): Codes for grouping and sorting goals.



Required Pattern: At least the following
..... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
...... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
...... code1..1codeSymbol in syntax defined by the system
Fixed Value: 87528-6
... description SΣ1..1CodeableConceptCode or text describing goal
Binding: SNOMEDCTClinicalFindings (example): Codes providing the details of a particular goal. This will generally be system or implementation guide-specific. In many systems, only the text element will be used.

.... EnclosedPreconditionExtension 0..1CodeableConceptEnclosed Precondition
URL: http://hl7.org/fhir/us/pacio-adi/StructureDefinition/adi-enclosedPrecondition-extension
... subject SΣ1..1Reference(US Core Patient Profile)Who this goal is intended for
... target SC0..*BackboneElementTarget outcome for the goal
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... due[x] SΣ0..1Reach goal on or before
..... dueDatedate
... expressedBy SΣ1..1Reference(US Core Patient Profile)Who's responsible for creating Goal?

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
Goal.lifecycleStatusrequiredGoalLifecycleStatus
Goal.categoryexampleGoalCategory
Goal.category:typeexamplePattern: LOINC code 87528-6
Goal.descriptionexampleSNOMEDCTClinicalFindings

Constraints

IdGradePath(s)DetailsRequirements
goal-subject-expressedbyerrorGoalsubject and expressedBy refer to the same patient
: subject = expressedBy
NameFlagsCard.TypeDescription & Constraintsdoco
.. Goal C0..*USCoreGoalProfileDescribes the intended objective(s) for a patient, group or organization
goal-subject-expressedby: subject and expressedBy refer to the same patient
... id Σ0..1idLogical id of this artifact
... meta Σ0..1MetaMetadata about the resource
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... text S1..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... extension 0..*ExtensionAdditional content defined by implementations
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier 0..*IdentifierExternal Ids for this goal
... lifecycleStatus ?!SΣ1..1codeproposed | planned | accepted | active | on-hold | completed | cancelled | entered-in-error | rejected
Binding: GoalLifecycleStatus (required)
... achievementStatus Σ0..1CodeableConceptin-progress | improving | worsening | no-change | achieved | sustaining | not-achieved | no-progress | not-attainable
Binding: GoalAchievementStatus (preferred): Indicates the progression, or lack thereof, towards the goal against the target.

... Slices for category SΣ1..*CodeableConceptE.g. Treatment, dietary, behavioral, etc.
Slice: Unordered, Open by value:$this
Binding: GoalCategory (example): Codes for grouping and sorting goals.


.... category:All Slices Content/Rules for all slices
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
..... coding Σ0..*CodingCode defined by a terminology system
..... text SΣ0..1stringPlain text representation of the concept
.... category:type SΣ1..1CodeableConceptE.g. Treatment, dietary, behavioral, etc.
Binding: GoalCategory (example): Codes for grouping and sorting goals.



Required Pattern: At least the following
..... id0..1stringUnique id for inter-element referencing
..... extension0..*ExtensionAdditional content defined by implementations
..... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
...... id0..1stringUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
...... version0..1stringVersion of the system - if relevant
...... code1..1codeSymbol in syntax defined by the system
Fixed Value: 87528-6
...... display0..1stringRepresentation defined by the system
...... userSelected0..1booleanIf this coding was chosen directly by the user
..... text0..1stringPlain text representation of the concept
... priority Σ0..1CodeableConcepthigh-priority | medium-priority | low-priority
Binding: GoalPriority (preferred): The level of importance associated with a goal.

... description SΣ1..1CodeableConceptCode or text describing goal
Binding: SNOMEDCTClinicalFindings (example): Codes providing the details of a particular goal. This will generally be system or implementation guide-specific. In many systems, only the text element will be used.

.... id 0..1stringUnique id for inter-element referencing
.... Slices for extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... EnclosedPreconditionExtension 0..1CodeableConceptEnclosed Precondition
URL: http://hl7.org/fhir/us/pacio-adi/StructureDefinition/adi-enclosedPrecondition-extension
.... coding Σ0..*CodingCode defined by a terminology system
.... text Σ0..1stringPlain text representation of the concept
... subject SΣ1..1Reference(US Core Patient Profile)Who this goal is intended for
... start[x] Σ0..1When goal pursuit begins
Binding: GoalStartEvent (example): Codes describing events that can trigger the initiation of a goal.

.... startDatedate
.... startCodeableConceptCodeableConcept
... target SC0..*BackboneElementTarget outcome for the goal
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... measure ΣC0..1CodeableConceptThe parameter whose value is being tracked
Binding: LOINCCodes (example): Codes to identify the value being tracked, e.g. body weight, blood pressure, or hemoglobin A1c level.

.... detail[x] ΣC0..1The target value to be achieved
Binding: (unbound) (example): Codes to identify the target value of the focus to be achieved to signify the fulfillment of the goal.

..... detailQuantityQuantity
..... detailRangeRange
..... detailCodeableConceptCodeableConcept
..... detailStringstring
..... detailBooleanboolean
..... detailIntegerinteger
..... detailRatioRatio
.... due[x] SΣ0..1Reach goal on or before
..... dueDatedate S
..... dueDurationDuration
... statusDate Σ0..1dateWhen goal status took effect
... statusReason 0..1stringReason for current status
... expressedBy SΣ1..1Reference(US Core Patient Profile)Who's responsible for creating Goal?
... addresses 0..*Reference(Condition | Observation | MedicationStatement | NutritionOrder | ServiceRequest | RiskAssessment)Issues addressed by this goal
... note 0..*AnnotationComments about the goal
... outcomeCode 0..*CodeableConceptWhat result was achieved regarding the goal?
Binding: SNOMEDCTClinicalFindings (example): The result of the goal; e.g. "25% increase in shoulder mobility", "Anxiety reduced to moderate levels". "15 kg weight loss sustained over 6 months".


... outcomeReference 0..*Reference(Observation)Observation that resulted from goal

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
Goal.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
Goal.lifecycleStatusrequiredGoalLifecycleStatus
Goal.achievementStatuspreferredGoalAchievementStatus
Goal.categoryexampleGoalCategory
Goal.category:typeexamplePattern: LOINC code 87528-6
Goal.prioritypreferredGoalPriority
Goal.descriptionexampleSNOMEDCTClinicalFindings
Goal.start[x]exampleGoalStartEvent
Goal.target.measureexampleLOINCCodes (a valid code from LOINC)
Goal.target.detail[x]example
Goal.outcomeCodeexampleSNOMEDCTClinicalFindings

Constraints

IdGradePath(s)DetailsRequirements
goal-subject-expressedbyerrorGoalsubject and expressedBy refer to the same patient
: subject = expressedBy

This structure is derived from USCoreGoalProfile

Summary

Mandatory: 4 elements
Must-Support: 5 elements

Structures

This structure refers to these other structures:

Extensions

This structure refers to these extensions:

Slices

This structure defines the following Slices:

  • The element Goal.category is sliced based on the value of value:$this

Differential View

This structure is derived from USCoreGoalProfile

NameFlagsCard.TypeDescription & Constraintsdoco
.. Goal C0..*USCoreGoalProfileDescribes the intended objective(s) for a patient, group or organization
goal-subject-expressedby: subject and expressedBy refer to the same patient
... text S1..1NarrativeText summary of the resource, for human interpretation
... Slices for category S1..*CodeableConceptE.g. Treatment, dietary, behavioral, etc.
Slice: Unordered, Open by value:$this
.... category:All Slices Content/Rules for all slices
..... text S0..1stringPlain text representation of the concept
.... category:type S1..1CodeableConceptE.g. Treatment, dietary, behavioral, etc.
Required Pattern: At least the following
..... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
...... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
...... code1..1codeSymbol in syntax defined by the system
Fixed Value: 87528-6
... description
.... EnclosedPreconditionExtension 0..1CodeableConceptEnclosed Precondition
URL: http://hl7.org/fhir/us/pacio-adi/StructureDefinition/adi-enclosedPrecondition-extension

doco Documentation for this format

Constraints

IdGradePath(s)DetailsRequirements
goal-subject-expressedbyerrorGoalsubject and expressedBy refer to the same patient
: subject = expressedBy

Key Elements View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Goal C0..*USCoreGoalProfileDescribes the intended objective(s) for a patient, group or organization
goal-subject-expressedby: subject and expressedBy refer to the same patient
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... text S1..1NarrativeText summary of the resource, for human interpretation
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... Slices for category SΣ1..*CodeableConceptE.g. Treatment, dietary, behavioral, etc.
Slice: Unordered, Open by value:$this
Binding: GoalCategory (example): Codes for grouping and sorting goals.


.... category:All Slices Content/Rules for all slices
..... text SΣ0..1stringPlain text representation of the concept
.... category:type SΣ1..1CodeableConceptE.g. Treatment, dietary, behavioral, etc.
Binding: GoalCategory (example): Codes for grouping and sorting goals.



Required Pattern: At least the following
..... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
...... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
...... code1..1codeSymbol in syntax defined by the system
Fixed Value: 87528-6
... description SΣ1..1CodeableConceptCode or text describing goal
Binding: SNOMEDCTClinicalFindings (example): Codes providing the details of a particular goal. This will generally be system or implementation guide-specific. In many systems, only the text element will be used.

.... EnclosedPreconditionExtension 0..1CodeableConceptEnclosed Precondition
URL: http://hl7.org/fhir/us/pacio-adi/StructureDefinition/adi-enclosedPrecondition-extension
... subject SΣ1..1Reference(US Core Patient Profile)Who this goal is intended for
... target SC0..*BackboneElementTarget outcome for the goal
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... due[x] SΣ0..1Reach goal on or before
..... dueDatedate
... expressedBy SΣ1..1Reference(US Core Patient Profile)Who's responsible for creating Goal?

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
Goal.lifecycleStatusrequiredGoalLifecycleStatus
Goal.categoryexampleGoalCategory
Goal.category:typeexamplePattern: LOINC code 87528-6
Goal.descriptionexampleSNOMEDCTClinicalFindings

Constraints

IdGradePath(s)DetailsRequirements
goal-subject-expressedbyerrorGoalsubject and expressedBy refer to the same patient
: subject = expressedBy

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Goal C0..*USCoreGoalProfileDescribes the intended objective(s) for a patient, group or organization
goal-subject-expressedby: subject and expressedBy refer to the same patient
... id Σ0..1idLogical id of this artifact
... meta Σ0..1MetaMetadata about the resource
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... text S1..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... extension 0..*ExtensionAdditional content defined by implementations
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier 0..*IdentifierExternal Ids for this goal
... lifecycleStatus ?!SΣ1..1codeproposed | planned | accepted | active | on-hold | completed | cancelled | entered-in-error | rejected
Binding: GoalLifecycleStatus (required)
... achievementStatus Σ0..1CodeableConceptin-progress | improving | worsening | no-change | achieved | sustaining | not-achieved | no-progress | not-attainable
Binding: GoalAchievementStatus (preferred): Indicates the progression, or lack thereof, towards the goal against the target.

... Slices for category SΣ1..*CodeableConceptE.g. Treatment, dietary, behavioral, etc.
Slice: Unordered, Open by value:$this
Binding: GoalCategory (example): Codes for grouping and sorting goals.


.... category:All Slices Content/Rules for all slices
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
..... coding Σ0..*CodingCode defined by a terminology system
..... text SΣ0..1stringPlain text representation of the concept
.... category:type SΣ1..1CodeableConceptE.g. Treatment, dietary, behavioral, etc.
Binding: GoalCategory (example): Codes for grouping and sorting goals.



Required Pattern: At least the following
..... id0..1stringUnique id for inter-element referencing
..... extension0..*ExtensionAdditional content defined by implementations
..... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
...... id0..1stringUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
...... version0..1stringVersion of the system - if relevant
...... code1..1codeSymbol in syntax defined by the system
Fixed Value: 87528-6
...... display0..1stringRepresentation defined by the system
...... userSelected0..1booleanIf this coding was chosen directly by the user
..... text0..1stringPlain text representation of the concept
... priority Σ0..1CodeableConcepthigh-priority | medium-priority | low-priority
Binding: GoalPriority (preferred): The level of importance associated with a goal.

... description SΣ1..1CodeableConceptCode or text describing goal
Binding: SNOMEDCTClinicalFindings (example): Codes providing the details of a particular goal. This will generally be system or implementation guide-specific. In many systems, only the text element will be used.

.... id 0..1stringUnique id for inter-element referencing
.... Slices for extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... EnclosedPreconditionExtension 0..1CodeableConceptEnclosed Precondition
URL: http://hl7.org/fhir/us/pacio-adi/StructureDefinition/adi-enclosedPrecondition-extension
.... coding Σ0..*CodingCode defined by a terminology system
.... text Σ0..1stringPlain text representation of the concept
... subject SΣ1..1Reference(US Core Patient Profile)Who this goal is intended for
... start[x] Σ0..1When goal pursuit begins
Binding: GoalStartEvent (example): Codes describing events that can trigger the initiation of a goal.

.... startDatedate
.... startCodeableConceptCodeableConcept
... target SC0..*BackboneElementTarget outcome for the goal
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... measure ΣC0..1CodeableConceptThe parameter whose value is being tracked
Binding: LOINCCodes (example): Codes to identify the value being tracked, e.g. body weight, blood pressure, or hemoglobin A1c level.

.... detail[x] ΣC0..1The target value to be achieved
Binding: (unbound) (example): Codes to identify the target value of the focus to be achieved to signify the fulfillment of the goal.

..... detailQuantityQuantity
..... detailRangeRange
..... detailCodeableConceptCodeableConcept
..... detailStringstring
..... detailBooleanboolean
..... detailIntegerinteger
..... detailRatioRatio
.... due[x] SΣ0..1Reach goal on or before
..... dueDatedate S
..... dueDurationDuration
... statusDate Σ0..1dateWhen goal status took effect
... statusReason 0..1stringReason for current status
... expressedBy SΣ1..1Reference(US Core Patient Profile)Who's responsible for creating Goal?
... addresses 0..*Reference(Condition | Observation | MedicationStatement | NutritionOrder | ServiceRequest | RiskAssessment)Issues addressed by this goal
... note 0..*AnnotationComments about the goal
... outcomeCode 0..*CodeableConceptWhat result was achieved regarding the goal?
Binding: SNOMEDCTClinicalFindings (example): The result of the goal; e.g. "25% increase in shoulder mobility", "Anxiety reduced to moderate levels". "15 kg weight loss sustained over 6 months".


... outcomeReference 0..*Reference(Observation)Observation that resulted from goal

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
Goal.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
Goal.lifecycleStatusrequiredGoalLifecycleStatus
Goal.achievementStatuspreferredGoalAchievementStatus
Goal.categoryexampleGoalCategory
Goal.category:typeexamplePattern: LOINC code 87528-6
Goal.prioritypreferredGoalPriority
Goal.descriptionexampleSNOMEDCTClinicalFindings
Goal.start[x]exampleGoalStartEvent
Goal.target.measureexampleLOINCCodes (a valid code from LOINC)
Goal.target.detail[x]example
Goal.outcomeCodeexampleSNOMEDCTClinicalFindings

Constraints

IdGradePath(s)DetailsRequirements
goal-subject-expressedbyerrorGoalsubject and expressedBy refer to the same patient
: subject = expressedBy

This structure is derived from USCoreGoalProfile

Summary

Mandatory: 4 elements
Must-Support: 5 elements

Structures

This structure refers to these other structures:

Extensions

This structure refers to these extensions:

Slices

This structure defines the following Slices:

  • The element Goal.category is sliced based on the value of value:$this

 

Other representations of profile: CSV, Excel, Schematron