MCC eCare Plan Implementation Guide
1.0.0 - STU1 United States of America flag

MCC eCare Plan Implementation Guide, published by HL7 International / Patient Care. 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-us-mcc/ and changes regularly. See the Directory of published versions

Resource Profile: MCCGoal - Detailed Descriptions

Active as of 2024-08-13

Definitions for the MCCGoal resource profile.

Guidance on how to interpret the contents of this table can be found here

0. Goal
2. Goal.extension
SlicingThis element introduces a set of slices on Goal.extension. The slices areUnordered and Open, and can be differentiated using the following discriminators:
  • value @ url
  • 4. Goal.extension:goal-acceptance
    Slice Namegoal-acceptance
    ShortInformation about the acceptance and relative priority assigned to the goal by the patient, practitioners and other stake-holders
    TypeExtension(Goal acceptance) (Complex Extension)
    Must Supporttrue
    6. Goal.extension:reasonRejected
    Slice NamereasonRejected
    ShortThe reason the goal was not accepted. Applies only if the status of the goal is rejected
    TypeExtension(Goal Reason Rejected) (Extension Type: CodeableConcept)
    Must Supporttrue
    8. Goal.extension:related-goal
    Slice Namerelated-goal
    ShortEstablishes a relationship between this goal and other goals. Such as related Milestone Goal.
    TypeExtension(Goal: Related Goal) (Complex Extension)
    Must Supporttrue
    10. Goal.achievementStatus
    Must Supporttrue
    12. Goal.priority
    Must Supporttrue
    14. Goal.expressedBy
    Must Supporttrue
    16. Goal.addresses
    Must Supporttrue
    18. Goal.outcomeReference
    Must Supporttrue

    Guidance on how to interpret the contents of this table can be found here

    0. 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.

    ShortDescribes the intended objective(s) for a patient, group or organization
    Comments

    -


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

    Control0..*
    Is Modifierfalse
    Must Supportfalse
    Summaryfalse
    Invariantsdom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources (contained.contained.empty())
    dom-3: If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource (contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty())
    dom-4: If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated (contained.meta.versionId.empty() and contained.meta.lastUpdated.empty())
    dom-5: If a resource is contained in another resource, it SHALL NOT have a security label (contained.meta.security.empty())
    dom-6: A resource should have narrative for robust management (text.`div`.exists())
    2. Goal.implicitRules
    Definition

    A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc.

    ShortA set of rules under which this content was created
    Comments

    Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element. Often, when used, the URL is a reference to an implementation guide that defines these special rules as part of it's narrative along with other profiles, value sets, etc.

    Control0..1
    Typeuri
    Is Modifiertrue because This element is labeled as a modifier because the implicit rules may provide additional knowledge about the resource that modifies it's meaning or interpretation
    Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
    Summarytrue
    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    4. Goal.extension
    Definition

    An Extension


    May be used to represent additional information that is not part of the basic definition of the resource. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

    ShortExtensionAdditional content defined by implementations
    Comments

    There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

    Control0..*
    TypeExtension
    Is Modifierfalse
    Summaryfalse
    Alternate Namesextensions, user content
    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
    SlicingThis element introduces a set of slices on Goal.extension. The slices areUnordered and Open, and can be differentiated using the following discriminators:
    • value @ url
    • 6. Goal.extension:goal-acceptance
      Slice Namegoal-acceptance
      Definition

      Information about the acceptance and relative priority assigned to the goal by the patient, practitioners and other stake-holders.

      ShortInformation about the acceptance and relative priority assigned to the goal by the patient, practitioners and other stake-holders
      Control0..*
      TypeExtension(Goal acceptance) (Complex Extension)
      Is Modifierfalse
      Must Supporttrue
      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
      ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
      8. Goal.extension:reasonRejected
      Slice NamereasonRejected
      Definition

      The reason the goal was not accepted. Applies only if the status of the goal is rejected.

      ShortThe reason the goal was not accepted. Applies only if the status of the goal is rejected
      Control0..1
      TypeExtension(Goal Reason Rejected) (Extension Type: CodeableConcept)
      Is Modifierfalse
      Must Supporttrue
      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
      ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
      ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
      ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
      10. Goal.extension:related-goal
      Slice Namerelated-goal
      Definition

      Establishes a relationship between this goal and other goals.

      ShortEstablishes a relationship between this goal and other goals. Such as related Milestone Goal.
      Control0..*
      TypeExtension(Goal: Related Goal) (Complex Extension)
      Is Modifierfalse
      Must Supporttrue
      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
      ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
      12. Goal.modifierExtension
      Definition

      May be used to represent additional information that is not part of the basic definition of the resource and that modifies the understanding of the element that contains it and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

      Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

      ShortExtensions that cannot be ignored
      Comments

      There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

      Control0..*
      TypeExtension
      Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the resource that contains them
      Summaryfalse
      Requirements

      Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

      Alternate Namesextensions, user content
      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
      ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
      14. Goal.lifecycleStatus
      Definition

      The state of the goal throughout its lifecycle.

      Short(USCDI) proposed | planned | accepted | active | on-hold | completed | cancelled | entered-in-error | rejectedproposed | planned | accepted | active | on-hold | completed | cancelled | entered-in-error | rejected
      Comments

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

      Control1..1
      BindingThe codes SHALL be taken from GoalLifecycleStatushttp://hl7.org/fhir/ValueSet/goal-status|4.0.1
      (required to http://hl7.org/fhir/ValueSet/goal-status)
      Typecode
      Is Modifiertrue because 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
      Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
      Must Supporttrue
      Summarytrue
      Requirements

      Allows knowing whether goal needs to be further tracked.

      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
      16. Goal.achievementStatus
      Definition

      Describes the progression, or lack thereof, towards the goal against the target.

      Shortin-progress | improving | worsening | no-change | achieved | sustaining | not-achieved | no-progress | not-attainable
      Control0..1
      BindingThe codes SHOULD be taken from GoalAchievementStatushttp://hl7.org/fhir/ValueSet/goal-achievement
      (preferred to http://hl7.org/fhir/ValueSet/goal-achievement)

      Indicates the progression, or lack thereof, towards the goal against the target.

      TypeCodeableConcept
      Is Modifierfalse
      Must Supporttrue
      Summarytrue
      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
      18. Goal.priority
      Definition

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

      Shorthigh-priority | medium-priority | low-priority
      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".

      Control0..1
      BindingThe codes SHOULD be taken from GoalPriorityhttp://hl7.org/fhir/ValueSet/goal-priority
      (preferred to http://hl7.org/fhir/ValueSet/goal-priority)

      The level of importance associated with a goal.

      TypeCodeableConcept
      Is Modifierfalse
      Must Supporttrue
      Summarytrue
      Requirements

      Used for sorting and presenting goals.

      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
      20. 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".

      Short(USCDI) Code or text describing goalCode or text describing goal
      Comments

      If no code is available, use CodeableConcept.text.

      Control1..1
      BindingUnless not suitable, these codes SHALL be taken from For example codes, see US Core Goal Codeshttp://hl7.org/fhir/ValueSet/clinical-findings
      (extensible to http://hl7.org/fhir/us/core/ValueSet/us-core-goal-description)

      Value set to describe the Goal


      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.

      TypeCodeableConcept
      Is Modifierfalse
      Must Supporttrue
      Summarytrue
      Requirements

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

      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
      22. Goal.subject
      Definition

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

      Short(USCDI) Who this goal is intended forWho this goal is intended for
      Control1..1
      TypeReference(US Core Patient Profile, Patient, Group, Organization)
      Is Modifierfalse
      Must Supporttrue
      Summarytrue
      Requirements

      Subject is optional to support annonymized reporting.

      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
      24. Goal.start[x]
      Definition

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

      Short(USCDI) When goal pursuit beginsWhen goal pursuit begins
      Control0..1
      BindingFor example codes, see GoalStartEventhttp://hl7.org/fhir/ValueSet/goal-start-event
      (example to http://hl7.org/fhir/ValueSet/goal-start-event)

      Codes describing events that can trigger the initiation of a goal.

      TypeChoice of: date, CodeableConcept
      [x] NoteSeeChoice of Data Typesfor further information about how to use [x]
      Is Modifierfalse
      Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
      Must Supporttrue
      Must Support Typesdate
      Summarytrue
      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.

      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
      26. Goal.target
      Definition

      Indicates what should be done by when.

      Short(USCDI) Target outcome for the goalTarget outcome for the goal
      Comments

      When multiple targets are present for a single goal instance, all targets must be met for the overall goal to be met.

      Control0..*
      This element is affected by the following invariants: gol-1
      TypeBackboneElement
      Is Modifierfalse
      Must Supporttrue
      Summaryfalse
      Requirements

      Allows the progress of the goal to be monitored against an observation or due date. Target is 0..* to support Observations with multiple components, such as blood pressure goals with both a systolic and diastolic target.

      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
      gol-1: Goal.target.measure is required if Goal.target.detail is populated ((detail.exists() and measure.exists()) or detail.exists().not())
      gol-1: Goal.target.measure is required if Goal.target.detail is populated ((detail.exists() and measure.exists()) or detail.exists().not())
      28. Goal.target.modifierExtension
      Definition

      May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

      Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

      ShortExtensions that cannot be ignored even if unrecognized
      Comments

      There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

      Control0..*
      TypeExtension
      Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
      Summarytrue
      Requirements

      Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

      Alternate Namesextensions, user content, modifiers
      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
      ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
      30. Goal.target.due[x]
      Definition

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

      Short(USCDI) Reach goal on or beforeReach goal on or before
      Control0..1
      TypeChoice of: date, Duration
      [x] NoteSeeChoice of Data Typesfor further information about how to use [x]
      Is Modifierfalse
      Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
      Must Supporttrue
      Must Support Typesdate
      Summarytrue
      Requirements

      Identifies when the goal should be evaluated.

      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
      32. Goal.expressedBy
      Definition

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

      ShortWho's responsible for creating Goal?
      Comments

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

      Control0..1
      TypeReference(Patient, Practitioner, PractitionerRole, RelatedPerson)
      Is Modifierfalse
      Must Supporttrue
      Must Support TypesNo must-support rules about the choice of types/profiles
      Summarytrue
      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
      34. Goal.addresses
      Definition

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

      ShortIssues addressed by this goal
      Control0..*
      TypeReference(Condition, Observation, MedicationStatement, NutritionOrder, ServiceRequest, RiskAssessment)
      Is Modifierfalse
      Must Supporttrue
      Must Support TypesNo must-support rules about the choice of types/profiles
      Summaryfalse
      Requirements

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

      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
      36. Goal.outcomeReference
      Definition

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

      ShortObservation that resulted from goal
      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.

      Control0..*
      TypeReference(Observation)
      Is Modifierfalse
      Must Supporttrue
      Summaryfalse
      Requirements

      Outcome tracking is a key aspect of care planning.

      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))

      Guidance on how to interpret the contents of this table can be found here

      0. Goal
      Definition

      -

      ShortDescribes the intended objective(s) for a patient, group or organization
      Comments

      -

      Control0..*
      Is Modifierfalse
      Must Supportfalse
      Summaryfalse
      Invariantsdom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources (contained.contained.empty())
      dom-3: If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource (contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty())
      dom-4: If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated (contained.meta.versionId.empty() and contained.meta.lastUpdated.empty())
      dom-5: If a resource is contained in another resource, it SHALL NOT have a security label (contained.meta.security.empty())
      dom-6: A resource should have narrative for robust management (text.`div`.exists())
      2. Goal.id
      Definition

      The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes.

      ShortLogical id of this artifact
      Comments

      The only time that a resource does not have an id is when it is being submitted to the server using a create operation.

      Control0..1
      Typeid
      Is Modifierfalse
      Summarytrue
      4. Goal.meta
      Definition

      The metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content might not always be associated with version changes to the resource.

      ShortMetadata about the resource
      Control0..1
      TypeMeta
      Is Modifierfalse
      Summarytrue
      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
      6. Goal.implicitRules
      Definition

      A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc.

      ShortA set of rules under which this content was created
      Comments

      Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element. Often, when used, the URL is a reference to an implementation guide that defines these special rules as part of it's narrative along with other profiles, value sets, etc.

      Control0..1
      Typeuri
      Is Modifiertrue because This element is labeled as a modifier because the implicit rules may provide additional knowledge about the resource that modifies it's meaning or interpretation
      Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
      Summarytrue
      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
      8. Goal.language
      Definition

      The base language in which the resource is written.

      ShortLanguage of the resource content
      Comments

      Language is provided to support indexing and accessibility (typically, services such as text to speech use the language tag). The html language tag in the narrative applies to the narrative. The language tag on the resource may be used to specify the language of other presentations generated from the data in the resource. Not all the content has to be in the base language. The Resource.language should not be assumed to apply to the narrative automatically. If a language is specified, it should it also be specified on the div element in the html (see rules in HTML5 for information about the relationship between xml:lang and the html lang attribute).

      Control0..1
      BindingThe codes SHOULD be taken from CommonLanguages
      (preferred to http://hl7.org/fhir/ValueSet/languages)

      A human language.

      Additional BindingsPurpose
      AllLanguagesMax Binding
      Typecode
      Is Modifierfalse
      Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
      Summaryfalse
      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
      10. Goal.text
      Definition

      A human-readable narrative that contains a summary of the resource and can be used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. Resource definitions may define what content should be represented in the narrative to ensure clinical safety.

      ShortText summary of the resource, for human interpretation
      Comments

      Contained resources do not have narrative. Resources that are not contained SHOULD have a narrative. In some cases, a resource may only have text with little or no additional discrete data (as long as all minOccurs=1 elements are satisfied). This may be necessary for data from legacy systems where information is captured as a "text blob" or where text is additionally entered raw or narrated and encoded information is added later.

      Control0..1
      TypeNarrative
      Is Modifierfalse
      Summaryfalse
      Alternate Namesnarrative, html, xhtml, display
      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
      12. Goal.contained
      Definition

      These resources do not have an independent existence apart from the resource that contains them - they cannot be identified independently, and nor can they have their own independent transaction scope.

      ShortContained, inline Resources
      Comments

      This should never be done when the content can be identified properly, as once identification is lost, it is extremely difficult (and context dependent) to restore it again. Contained resources may have profiles and tags In their meta elements, but SHALL NOT have security labels.

      Control0..*
      TypeResource
      Is Modifierfalse
      Summaryfalse
      Alternate Namesinline resources, anonymous resources, contained resources
      14. Goal.extension
      Definition

      An Extension

      ShortExtension
      Control0..*
      TypeExtension
      Is Modifierfalse
      Summaryfalse
      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
      ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
      SlicingThis element introduces a set of slices on Goal.extension. The slices areUnordered and Open, and can be differentiated using the following discriminators:
      • value @ url
      • 16. Goal.extension:goal-acceptance
        Slice Namegoal-acceptance
        Definition

        Information about the acceptance and relative priority assigned to the goal by the patient, practitioners and other stake-holders.

        ShortInformation about the acceptance and relative priority assigned to the goal by the patient, practitioners and other stake-holders
        Control0..*
        TypeExtension(Goal acceptance) (Complex Extension)
        Is Modifierfalse
        Must Supporttrue
        Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
        ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
        18. Goal.extension:reasonRejected
        Slice NamereasonRejected
        Definition

        The reason the goal was not accepted. Applies only if the status of the goal is rejected.

        ShortThe reason the goal was not accepted. Applies only if the status of the goal is rejected
        Control0..1
        TypeExtension(Goal Reason Rejected) (Extension Type: CodeableConcept)
        Is Modifierfalse
        Must Supporttrue
        Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
        ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
        20. Goal.extension:related-goal
        Slice Namerelated-goal
        Definition

        Establishes a relationship between this goal and other goals.

        ShortEstablishes a relationship between this goal and other goals. Such as related Milestone Goal.
        Control0..*
        TypeExtension(Goal: Related Goal) (Complex Extension)
        Is Modifierfalse
        Must Supporttrue
        Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
        ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
        22. Goal.modifierExtension
        Definition

        May be used to represent additional information that is not part of the basic definition of the resource and that modifies the understanding of the element that contains it and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

        Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

        ShortExtensions that cannot be ignored
        Comments

        There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

        Control0..*
        TypeExtension
        Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the resource that contains them
        Summaryfalse
        Requirements

        Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

        Alternate Namesextensions, user content
        Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
        ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
        24. Goal.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.

        ShortExternal Ids for this goal
        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.

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

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

        Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
        26. Goal.lifecycleStatus
        Definition

        The state of the goal throughout its lifecycle.

        Short(USCDI) proposed | planned | accepted | active | on-hold | completed | cancelled | entered-in-error | rejected
        Comments

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

        Control1..1
        BindingThe codes SHALL be taken from GoalLifecycleStatus
        (required to http://hl7.org/fhir/ValueSet/goal-status)
        Typecode
        Is Modifiertrue because 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
        Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
        Must Supporttrue
        Summarytrue
        Requirements

        Allows knowing whether goal needs to be further tracked.

        Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
        28. Goal.achievementStatus
        Definition

        Describes the progression, or lack thereof, towards the goal against the target.

        Shortin-progress | improving | worsening | no-change | achieved | sustaining | not-achieved | no-progress | not-attainable
        Control0..1
        BindingThe codes SHOULD be taken from GoalAchievementStatus
        (preferred to http://hl7.org/fhir/ValueSet/goal-achievement)

        Indicates the progression, or lack thereof, towards the goal against the target.

        TypeCodeableConcept
        Is Modifierfalse
        Must Supporttrue
        Summarytrue
        Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
        30. Goal.category
        Definition

        Indicates a category the goal falls within.

        ShortE.g. Treatment, dietary, behavioral, etc.
        Control0..*
        BindingFor example codes, see GoalCategory
        (example to http://hl7.org/fhir/ValueSet/goal-category)

        Codes for grouping and sorting goals.

        TypeCodeableConcept
        Is Modifierfalse
        Summarytrue
        Requirements

        Allows goals to be filtered and sorted.

        Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
        32. Goal.priority
        Definition

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

        Shorthigh-priority | medium-priority | low-priority
        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".

        Control0..1
        BindingThe codes SHOULD be taken from GoalPriority
        (preferred to http://hl7.org/fhir/ValueSet/goal-priority)

        The level of importance associated with a goal.

        TypeCodeableConcept
        Is Modifierfalse
        Must Supporttrue
        Summarytrue
        Requirements

        Used for sorting and presenting goals.

        Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
        34. 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".

        Short(USCDI) Code or text describing goal
        Comments

        If no code is available, use CodeableConcept.text.

        Control1..1
        BindingUnless not suitable, these codes SHALL be taken from US Core Goal Codes
        (extensible to http://hl7.org/fhir/us/core/ValueSet/us-core-goal-description)

        Value set to describe the Goal

        TypeCodeableConcept
        Is Modifierfalse
        Must Supporttrue
        Summarytrue
        Requirements

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

        Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
        36. Goal.subject
        Definition

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

        Short(USCDI) Who this goal is intended for
        Control1..1
        TypeReference(US Core Patient Profile)
        Is Modifierfalse
        Must Supporttrue
        Summarytrue
        Requirements

        Subject is optional to support annonymized reporting.

        Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
        38. Goal.start[x]
        Definition

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

        Short(USCDI) When goal pursuit begins
        Control0..1
        BindingFor example codes, see GoalStartEvent
        (example to http://hl7.org/fhir/ValueSet/goal-start-event)

        Codes describing events that can trigger the initiation of a goal.

        TypeChoice of: date, CodeableConcept
        [x] NoteSeeChoice of Data Typesfor further information about how to use [x]
        Is Modifierfalse
        Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
        Must Supporttrue
        Must Support Typesdate
        Summarytrue
        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.

        Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
        40. Goal.target
        Definition

        Indicates what should be done by when.

        Short(USCDI) Target outcome for the goal
        Comments

        When multiple targets are present for a single goal instance, all targets must be met for the overall goal to be met.

        Control0..*
        This element is affected by the following invariants: gol-1
        TypeBackboneElement
        Is Modifierfalse
        Must Supporttrue
        Summaryfalse
        Requirements

        Allows the progress of the goal to be monitored against an observation or due date. Target is 0..* to support Observations with multiple components, such as blood pressure goals with both a systolic and diastolic target.

        Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
        gol-1: Goal.target.measure is required if Goal.target.detail is populated ((detail.exists() and measure.exists()) or detail.exists().not())
        42. Goal.target.id
        Definition

        Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

        ShortUnique id for inter-element referencing
        Control0..1
        Typestring
        Is Modifierfalse
        XML FormatIn the XML format, this property is represented as an attribute.
        Summaryfalse
        44. Goal.target.extension
        Definition

        May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

        ShortAdditional content defined by implementations
        Comments

        There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

        Control0..*
        TypeExtension
        Is Modifierfalse
        Summaryfalse
        Alternate Namesextensions, user content
        Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
        ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
        46. Goal.target.modifierExtension
        Definition

        May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

        Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

        ShortExtensions that cannot be ignored even if unrecognized
        Comments

        There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

        Control0..*
        TypeExtension
        Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
        Summarytrue
        Requirements

        Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

        Alternate Namesextensions, user content, modifiers
        Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
        ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
        48. Goal.target.measure
        Definition

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

        ShortThe parameter whose value is being tracked
        Control0..1
        This element is affected by the following invariants: gol-1
        BindingFor example codes, see LOINCCodes
        (example to http://hl7.org/fhir/ValueSet/observation-codes)

        Codes to identify the value being tracked, e.g. body weight, blood pressure, or hemoglobin A1c level.

        TypeCodeableConcept
        Is Modifierfalse
        Summarytrue
        Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
        50. 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.

        ShortThe target value to be achieved
        Comments

        A CodeableConcept with just a text would be used instead of a string if the field was usually coded, or if the type associated with the Goal.target.measure defines a coded value.

        Control0..1
        This element is affected by the following invariants: gol-1
        Binding

        Codes to identify the target value of the focus to be achieved to signify the fulfillment of the goal.

        TypeChoice of: Quantity, Range, CodeableConcept, string, boolean, integer, Ratio
        [x] NoteSeeChoice of Data Typesfor further information about how to use [x]
        Is Modifierfalse
        Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
        Summarytrue
        Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
        52. Goal.target.due[x]
        Definition

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

        Short(USCDI) Reach goal on or before
        Control0..1
        TypeChoice of: date, Duration
        [x] NoteSeeChoice of Data Typesfor further information about how to use [x]
        Is Modifierfalse
        Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
        Must Supporttrue
        Must Support Typesdate
        Summarytrue
        Requirements

        Identifies when the goal should be evaluated.

        Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
        54. Goal.statusDate
        Definition

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

        ShortWhen goal status took effect
        Comments

        To see the date for past statuses, query history.

        Control0..1
        Typedate
        Is Modifierfalse
        Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
        Summarytrue
        Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
        56. Goal.statusReason
        Definition

        Captures the reason for the current status.

        ShortReason for current status
        Comments

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

        Control0..1
        Typestring
        Is Modifierfalse
        Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
        Summaryfalse
        Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
        58. Goal.expressedBy
        Definition

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

        ShortWho's responsible for creating Goal?
        Comments

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

        Control0..1
        TypeReference(Patient, Practitioner, PractitionerRole, RelatedPerson)
        Is Modifierfalse
        Must Supporttrue
        Must Support TypesNo must-support rules about the choice of types/profiles
        Summarytrue
        Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
        60. Goal.addresses
        Definition

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

        ShortIssues addressed by this goal
        Control0..*
        TypeReference(Condition, Observation, MedicationStatement, NutritionOrder, ServiceRequest, RiskAssessment)
        Is Modifierfalse
        Must Supporttrue
        Must Support TypesNo must-support rules about the choice of types/profiles
        Summaryfalse
        Requirements

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

        Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
        62. Goal.note
        Definition

        Any comments related to the goal.

        ShortComments about the goal
        Comments

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

        Control0..*
        TypeAnnotation
        Is Modifierfalse
        Summaryfalse
        Requirements

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

        Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
        64. Goal.outcomeCode
        Definition

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

        ShortWhat result was achieved regarding the goal?
        Comments

        Note that this should not duplicate the goal status.

        Control0..*
        BindingFor example codes, see SNOMEDCTClinicalFindings
        (example to http://hl7.org/fhir/ValueSet/clinical-findings)

        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".

        TypeCodeableConcept
        Is Modifierfalse
        Summaryfalse
        Requirements

        Outcome tracking is a key aspect of care planning.

        Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
        66. Goal.outcomeReference
        Definition

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

        ShortObservation that resulted from goal
        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.

        Control0..*
        TypeReference(Observation)
        Is Modifierfalse
        Must Supporttrue
        Summaryfalse
        Requirements

        Outcome tracking is a key aspect of care planning.

        Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))