PACIO Advance Directive Interoperability Implementation Guide
0.1.0 - STU 1 Ballot

PACIO Advance Directive Interoperability Implementation Guide, published by HL7 Patient Empowerment Working Group. This is not an authorized publication; it is the continuous build for version 0.1.0). 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 Goal

Defining URL:http://hl7.org/fhir/us/pacio-adi/StructureDefinition/PADI-Goal
Version:0.1.0
Name:PADIGoal
Title:ADI Goal
Status:Active as of 12/3/21, 11:52 PM
Definition:

This profile defines the base requirements for all ADI Goals.

Publisher:HL7 Patient Empowerment Working Group
Source Resource:XML / JSON / Turtle

The official URL for this profile is:

http://hl7.org/fhir/us/pacio-adi/StructureDefinition/PADI-Goal

The ADI goal represents the patient’s advance healthcare decision goals for the medical interventions that will be part of the clinician-authored care plan that will drive treatment. The patient’s documented goals of the medical care they will receive is based on the context or condition specified, and is intended to guide the provider-authored interventions that will be documented by the care team providing the treatment interventions that meet those documented patient goals. This allows a person-centered approach to care planning that reflects the specific goals, preferences, and priorities of that person which can then be merged with the clinical care plan so as to enable a jointly developed plan of care between the provider and person receiving care.

Formal Views of Profile Content

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

This structure is derived from USCoreGoalProfile

Summary

Mandatory: 2 elements
Must-Support: 7 elements

Structures

This structure refers to these other structures:

Extensions

This structure refers to these extensions:

This structure is derived from USCoreGoalProfile

NameFlagsCard.TypeDescription & Constraintsdoco
.. Goal I0..*USCoreGoalProfileThis is an abstract profile
Describes 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
... category S0..*CodeableConceptE.g. Treatment, dietary, behavioral, etc.
.... text S0..1stringPlain text representation of the concept
... description
.... padi-contextualValue-extension 0..1(Complex)Contextual Value
URL: http://hl7.org/fhir/us/pacio-adi/StructureDefinition/padi-contextualValue-extension
.... measure S0..1CodeableConceptThe parameter whose value is being tracked
.... detail[x] S0..1Quantity, Range, CodeableConcept, string, boolean, integer, RatioThe target value to be achieved
... expressedBy S1..1Reference(US Core Patient Profile)Who's responsible for creating Goal?
... note S0..*AnnotationComments about the goal

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraintsdoco
.. Goal I0..*USCoreGoalProfileThis is an abstract profile
Describes the intended objective(s) for a patient, group or organization
goal-subject-expressedby: subject and expressedBy refer to the same patient
... id Σ0..1stringLogical 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.

... category SΣ0..*CodeableConceptE.g. Treatment, dietary, behavioral, etc.
Binding: GoalCategory (example): Codes for grouping and sorting goals.


.... id 0..1stringUnique id for inter-element referencing
.... Slices for 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
... 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
.... padi-contextualValue-extension 0..1(Complex)Contextual Value
URL: http://hl7.org/fhir/us/pacio-adi/StructureDefinition/padi-contextualValue-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 SI0..*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 SΣI0..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] SΣI0..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 S0..*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
NameFlagsCard.TypeDescription & Constraintsdoco
.. Goal I0..*USCoreGoalProfileThis is an abstract profile
Describes the intended objective(s) for a patient, group or organization
goal-subject-expressedby: subject and expressedBy refer to the same patient
... text 1..1NarrativeText summary of the resource, for human interpretation
... lifecycleStatus ?!Σ1..1codeproposed | planned | accepted | active | on-hold | completed | cancelled | entered-in-error | rejected
Binding: GoalLifecycleStatus (required)
... category Σ0..*CodeableConceptE.g. Treatment, dietary, behavioral, etc.
Binding: GoalCategory (example): Codes for grouping and sorting goals.


.... text Σ0..1stringPlain text representation of the concept
... subject Σ1..1Reference(US Core Patient Profile)Who this goal is intended for
... target I0..*BackboneElementTarget outcome for the goal
.... measure ΣI0..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] ΣI0..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] Σ0..1Reach goal on or before
..... dueDatedate
... expressedBy Σ1..1Reference(US Core Patient Profile)Who's responsible for creating Goal?
... note 0..*AnnotationComments about the goal

doco Documentation for this format

This structure is derived from USCoreGoalProfile

Summary

Mandatory: 2 elements
Must-Support: 7 elements

Structures

This structure refers to these other structures:

Extensions

This structure refers to these extensions:

Differential View

This structure is derived from USCoreGoalProfile

NameFlagsCard.TypeDescription & Constraintsdoco
.. Goal I0..*USCoreGoalProfileThis is an abstract profile
Describes 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
... category S0..*CodeableConceptE.g. Treatment, dietary, behavioral, etc.
.... text S0..1stringPlain text representation of the concept
... description
.... padi-contextualValue-extension 0..1(Complex)Contextual Value
URL: http://hl7.org/fhir/us/pacio-adi/StructureDefinition/padi-contextualValue-extension
.... measure S0..1CodeableConceptThe parameter whose value is being tracked
.... detail[x] S0..1Quantity, Range, CodeableConcept, string, boolean, integer, RatioThe target value to be achieved
... expressedBy S1..1Reference(US Core Patient Profile)Who's responsible for creating Goal?
... note S0..*AnnotationComments about the goal

doco Documentation for this format

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Goal I0..*USCoreGoalProfileThis is an abstract profile
Describes the intended objective(s) for a patient, group or organization
goal-subject-expressedby: subject and expressedBy refer to the same patient
... id Σ0..1stringLogical 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.

... category SΣ0..*CodeableConceptE.g. Treatment, dietary, behavioral, etc.
Binding: GoalCategory (example): Codes for grouping and sorting goals.


.... id 0..1stringUnique id for inter-element referencing
.... Slices for 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
... 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
.... padi-contextualValue-extension 0..1(Complex)Contextual Value
URL: http://hl7.org/fhir/us/pacio-adi/StructureDefinition/padi-contextualValue-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 SI0..*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 SΣI0..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] SΣI0..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 S0..*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

 

Other representations of profile: CSV, Excel, Schematron

Terminology Bindings

PathConformanceValueSet
Goal.languagepreferredCommonLanguages
Max Binding: AllLanguages
Goal.lifecycleStatusrequiredGoalLifecycleStatus
Goal.achievementStatuspreferredGoalAchievementStatus
Goal.categoryexampleGoalCategory
Goal.prioritypreferredGoalPriority
Goal.descriptionexampleSNOMEDCTClinicalFindings
Goal.start[x]exampleGoalStartEvent
Goal.target.measureexampleLOINCCodes
Goal.target.detail[x]example
Goal.outcomeCodeexampleSNOMEDCTClinicalFindings

Constraints

IdPathDetailsRequirements
goal-subject-expressedbyGoalsubject and expressedBy refer to the same patient
: subject = expressedBy