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: Multiple Chronic Condition Care Plan Goal

Official URL: http://hl7.org/fhir/us/mcc/StructureDefinition/MCCGoal Version: 1.0.0
Active as of 2024-07-09 Computable Name: MCCGoal

This profile constrains US Core Goal for use in the MCC FHIR Care Plan or other FHIR Care Plans.

The US Core Goal sets minimum expectations for the Goal resource to record, search, and fetch goals associated with a patient, including information about a Social Determinants of Health-related goals. It identifies which core elements, extensions, vocabularies and value sets SHALL be present in the resource when using this profile. In addition to the requirements set forth in US Core Goal this derived profile is designed to add requirements to the following elements:

  • Goal.expressedBy (Must Support)
  • Goal.addresses (Must Support)
  • Goal.outcomeReference (Must Support)
  • Goal.extension:goal-acceptance (Must Support)
  • Goal.extension:reasonRejected (Must Support)
  • Goal.extension:related-goal (Must Support)

Although no MCC Goal value sets were developed for this guide beyond what is present in the US Core Goal profile, please see the MCC Goal Value Set library page for terminology and value set guidance specific to this Goal profile.

See the MCC Care Plan SDOH Guidance page for more information when exchanging Social Determinants of Health (SDOH) goals.

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 0..* USCoreGoalProfile Describes the intended objective(s) for a patient, group or organization
... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
.... goal-acceptance S 0..* (Complex) Information about the acceptance and relative priority assigned to the goal by the patient, practitioners and other stake-holders
URL: http://hl7.org/fhir/StructureDefinition/goal-acceptance
.... reasonRejected S 0..1 CodeableConcept The reason the goal was not accepted. Applies only if the status of the goal is rejected
URL: http://hl7.org/fhir/StructureDefinition/goal-reasonRejected
.... related-goal S 0..* (Complex) Establishes a relationship between this goal and other goals. Such as related Milestone Goal.
URL: http://hl7.org/fhir/StructureDefinition/goal-relationship
... achievementStatus S 0..1 CodeableConcept in-progress | improving | worsening | no-change | achieved | sustaining | not-achieved | no-progress | not-attainable
... priority S 0..1 CodeableConcept high-priority | medium-priority | low-priority
... addresses S 0..* Reference(Condition | Observation | MedicationStatement | NutritionOrder | ServiceRequest | RiskAssessment) Issues addressed by this goal
... outcomeReference S 0..* Reference(Observation) Observation that resulted from goal

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraintsdoco
.. Goal 0..* USCoreGoalProfile Describes the intended objective(s) for a patient, group or organization
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
.... goal-acceptance S 0..* (Complex) Information about the acceptance and relative priority assigned to the goal by the patient, practitioners and other stake-holders
URL: http://hl7.org/fhir/StructureDefinition/goal-acceptance
.... reasonRejected S 0..1 CodeableConcept The reason the goal was not accepted. Applies only if the status of the goal is rejected
URL: http://hl7.org/fhir/StructureDefinition/goal-reasonRejected
.... related-goal S 0..* (Complex) Establishes a relationship between this goal and other goals. Such as related Milestone Goal.
URL: http://hl7.org/fhir/StructureDefinition/goal-relationship
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... achievementStatus SΣ 0..1 CodeableConcept in-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.

... priority SΣ 0..1 CodeableConcept high-priority | medium-priority | low-priority
Binding: GoalPriority (preferred): The level of importance associated with a goal.

... description SΣ 1..1 CodeableConcept (USCDI) Code or text describing goal
Binding: US Core Goal Codes (extensible): Value set to describe the Goal

... subject SΣ 1..1 Reference(US Core Patient Profile) (USCDI) Who this goal is intended for
... start[x] SΣ 0..1 (USCDI) When goal pursuit begins
Binding: GoalStartEvent (example): Codes describing events that can trigger the initiation of a goal.

.... startDate date
... target SC 0..* BackboneElement (USCDI) Target outcome for the goal
gol-1: Goal.target.measure is required if Goal.target.detail is populated
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... due[x] SΣ 0..1 (USCDI) Reach goal on or before
..... dueDate date
... expressedBy SΣ 0..1 Reference(Patient | Practitioner | PractitionerRole | RelatedPerson) Who's responsible for creating Goal?
... addresses S 0..* Reference(Condition | Observation | MedicationStatement | NutritionOrder | ServiceRequest | RiskAssessment) Issues addressed by this goal
... outcomeReference S 0..* Reference(Observation) Observation that resulted from goal

doco Documentation for this format

Terminology Bindings

PathConformanceValueSetURI
Goal.lifecycleStatusrequiredGoalLifecycleStatus
http://hl7.org/fhir/ValueSet/goal-status
from the FHIR Standard
Goal.achievementStatuspreferredGoalAchievementStatus
http://hl7.org/fhir/ValueSet/goal-achievement
from the FHIR Standard
Goal.prioritypreferredGoalPriority
http://hl7.org/fhir/ValueSet/goal-priority
from the FHIR Standard
Goal.descriptionextensibleUSCoreGoalCodes
http://hl7.org/fhir/us/core/ValueSet/us-core-goal-description
Goal.start[x]exampleGoalStartEvent
http://hl7.org/fhir/ValueSet/goal-start-event
from the FHIR Standard

Constraints

IdGradePath(s)DetailsRequirements
dom-2errorGoalIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3errorGoalIf 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-4errorGoalIf 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-5errorGoalIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6best practiceGoalA resource should have narrative for robust management
: text.`div`.exists()
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()
gol-1errorGoal.targetGoal.target.measure is required if Goal.target.detail is populated
: (detail.exists() and measure.exists()) or detail.exists().not()
NameFlagsCard.TypeDescription & Constraintsdoco
.. Goal 0..* USCoreGoalProfile Describes the intended objective(s) for a patient, group or organization
... id Σ 0..1 id Logical id of this artifact
... meta Σ 0..1 Meta Metadata about the resource
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... text 0..1 Narrative Text summary of the resource, for human interpretation
... contained 0..* Resource Contained, inline Resources
... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
.... goal-acceptance S 0..* (Complex) Information about the acceptance and relative priority assigned to the goal by the patient, practitioners and other stake-holders
URL: http://hl7.org/fhir/StructureDefinition/goal-acceptance
.... reasonRejected S 0..1 CodeableConcept The reason the goal was not accepted. Applies only if the status of the goal is rejected
URL: http://hl7.org/fhir/StructureDefinition/goal-reasonRejected
.... related-goal S 0..* (Complex) Establishes a relationship between this goal and other goals. Such as related Milestone Goal.
URL: http://hl7.org/fhir/StructureDefinition/goal-relationship
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... identifier 0..* Identifier External Ids for this goal
... lifecycleStatus ?!SΣ 1..1 code (USCDI) proposed | planned | accepted | active | on-hold | completed | cancelled | entered-in-error | rejected
Binding: GoalLifecycleStatus (required)
... achievementStatus SΣ 0..1 CodeableConcept in-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 Σ 0..* CodeableConcept E.g. Treatment, dietary, behavioral, etc.
Binding: GoalCategory (example): Codes for grouping and sorting goals.


... priority SΣ 0..1 CodeableConcept high-priority | medium-priority | low-priority
Binding: GoalPriority (preferred): The level of importance associated with a goal.

... description SΣ 1..1 CodeableConcept (USCDI) Code or text describing goal
Binding: US Core Goal Codes (extensible): Value set to describe the Goal

... subject SΣ 1..1 Reference(US Core Patient Profile) (USCDI) Who this goal is intended for
... start[x] SΣ 0..1 (USCDI) When goal pursuit begins
Binding: GoalStartEvent (example): Codes describing events that can trigger the initiation of a goal.

.... startDate date S
.... startCodeableConcept CodeableConcept
... target SC 0..* BackboneElement (USCDI) Target outcome for the goal
gol-1: Goal.target.measure is required if Goal.target.detail is populated
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... measure ΣC 0..1 CodeableConcept The 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] ΣC 0..1 The 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.

..... detailQuantity Quantity
..... detailRange Range
..... detailCodeableConcept CodeableConcept
..... detailString string
..... detailBoolean boolean
..... detailInteger integer
..... detailRatio Ratio
.... due[x] SΣ 0..1 (USCDI) Reach goal on or before
..... dueDate date S
..... dueDuration Duration
... statusDate Σ 0..1 date When goal status took effect
... statusReason 0..1 string Reason for current status
... expressedBy SΣ 0..1 Reference(Patient | Practitioner | PractitionerRole | RelatedPerson) Who's responsible for creating Goal?
... addresses S 0..* Reference(Condition | Observation | MedicationStatement | NutritionOrder | ServiceRequest | RiskAssessment) Issues addressed by this goal
... note 0..* Annotation Comments about the goal
... outcomeCode 0..* CodeableConcept What 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 S 0..* Reference(Observation) Observation that resulted from goal

doco Documentation for this format

Terminology Bindings

PathConformanceValueSetURI
Goal.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
http://hl7.org/fhir/ValueSet/languages
from the FHIR Standard
Goal.lifecycleStatusrequiredGoalLifecycleStatus
http://hl7.org/fhir/ValueSet/goal-status
from the FHIR Standard
Goal.achievementStatuspreferredGoalAchievementStatus
http://hl7.org/fhir/ValueSet/goal-achievement
from the FHIR Standard
Goal.categoryexampleGoalCategory
http://hl7.org/fhir/ValueSet/goal-category
from the FHIR Standard
Goal.prioritypreferredGoalPriority
http://hl7.org/fhir/ValueSet/goal-priority
from the FHIR Standard
Goal.descriptionextensibleUSCoreGoalCodes
http://hl7.org/fhir/us/core/ValueSet/us-core-goal-description
Goal.start[x]exampleGoalStartEvent
http://hl7.org/fhir/ValueSet/goal-start-event
from the FHIR Standard
Goal.target.measureexampleLOINCCodes (a valid code from LOINC)
http://hl7.org/fhir/ValueSet/observation-codes
from the FHIR Standard
Goal.target.detail[x]example
Goal.outcomeCodeexampleSNOMEDCTClinicalFindings
http://hl7.org/fhir/ValueSet/clinical-findings
from the FHIR Standard

Constraints

IdGradePath(s)DetailsRequirements
dom-2errorGoalIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3errorGoalIf 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-4errorGoalIf 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-5errorGoalIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6best practiceGoalA resource should have narrative for robust management
: text.`div`.exists()
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()
gol-1errorGoal.targetGoal.target.measure is required if Goal.target.detail is populated
: (detail.exists() and measure.exists()) or detail.exists().not()

Differential View

This structure is derived from USCoreGoalProfile

NameFlagsCard.TypeDescription & Constraintsdoco
.. Goal 0..* USCoreGoalProfile Describes the intended objective(s) for a patient, group or organization
... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
.... goal-acceptance S 0..* (Complex) Information about the acceptance and relative priority assigned to the goal by the patient, practitioners and other stake-holders
URL: http://hl7.org/fhir/StructureDefinition/goal-acceptance
.... reasonRejected S 0..1 CodeableConcept The reason the goal was not accepted. Applies only if the status of the goal is rejected
URL: http://hl7.org/fhir/StructureDefinition/goal-reasonRejected
.... related-goal S 0..* (Complex) Establishes a relationship between this goal and other goals. Such as related Milestone Goal.
URL: http://hl7.org/fhir/StructureDefinition/goal-relationship
... achievementStatus S 0..1 CodeableConcept in-progress | improving | worsening | no-change | achieved | sustaining | not-achieved | no-progress | not-attainable
... priority S 0..1 CodeableConcept high-priority | medium-priority | low-priority
... addresses S 0..* Reference(Condition | Observation | MedicationStatement | NutritionOrder | ServiceRequest | RiskAssessment) Issues addressed by this goal
... outcomeReference S 0..* Reference(Observation) Observation that resulted from goal

doco Documentation for this format

Key Elements View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Goal 0..* USCoreGoalProfile Describes the intended objective(s) for a patient, group or organization
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
.... goal-acceptance S 0..* (Complex) Information about the acceptance and relative priority assigned to the goal by the patient, practitioners and other stake-holders
URL: http://hl7.org/fhir/StructureDefinition/goal-acceptance
.... reasonRejected S 0..1 CodeableConcept The reason the goal was not accepted. Applies only if the status of the goal is rejected
URL: http://hl7.org/fhir/StructureDefinition/goal-reasonRejected
.... related-goal S 0..* (Complex) Establishes a relationship between this goal and other goals. Such as related Milestone Goal.
URL: http://hl7.org/fhir/StructureDefinition/goal-relationship
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... achievementStatus SΣ 0..1 CodeableConcept in-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.

... priority SΣ 0..1 CodeableConcept high-priority | medium-priority | low-priority
Binding: GoalPriority (preferred): The level of importance associated with a goal.

... description SΣ 1..1 CodeableConcept (USCDI) Code or text describing goal
Binding: US Core Goal Codes (extensible): Value set to describe the Goal

... subject SΣ 1..1 Reference(US Core Patient Profile) (USCDI) Who this goal is intended for
... start[x] SΣ 0..1 (USCDI) When goal pursuit begins
Binding: GoalStartEvent (example): Codes describing events that can trigger the initiation of a goal.

.... startDate date
... target SC 0..* BackboneElement (USCDI) Target outcome for the goal
gol-1: Goal.target.measure is required if Goal.target.detail is populated
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... due[x] SΣ 0..1 (USCDI) Reach goal on or before
..... dueDate date
... expressedBy SΣ 0..1 Reference(Patient | Practitioner | PractitionerRole | RelatedPerson) Who's responsible for creating Goal?
... addresses S 0..* Reference(Condition | Observation | MedicationStatement | NutritionOrder | ServiceRequest | RiskAssessment) Issues addressed by this goal
... outcomeReference S 0..* Reference(Observation) Observation that resulted from goal

doco Documentation for this format

Terminology Bindings

PathConformanceValueSetURI
Goal.lifecycleStatusrequiredGoalLifecycleStatus
http://hl7.org/fhir/ValueSet/goal-status
from the FHIR Standard
Goal.achievementStatuspreferredGoalAchievementStatus
http://hl7.org/fhir/ValueSet/goal-achievement
from the FHIR Standard
Goal.prioritypreferredGoalPriority
http://hl7.org/fhir/ValueSet/goal-priority
from the FHIR Standard
Goal.descriptionextensibleUSCoreGoalCodes
http://hl7.org/fhir/us/core/ValueSet/us-core-goal-description
Goal.start[x]exampleGoalStartEvent
http://hl7.org/fhir/ValueSet/goal-start-event
from the FHIR Standard

Constraints

IdGradePath(s)DetailsRequirements
dom-2errorGoalIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3errorGoalIf 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-4errorGoalIf 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-5errorGoalIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6best practiceGoalA resource should have narrative for robust management
: text.`div`.exists()
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()
gol-1errorGoal.targetGoal.target.measure is required if Goal.target.detail is populated
: (detail.exists() and measure.exists()) or detail.exists().not()

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Goal 0..* USCoreGoalProfile Describes the intended objective(s) for a patient, group or organization
... id Σ 0..1 id Logical id of this artifact
... meta Σ 0..1 Meta Metadata about the resource
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... text 0..1 Narrative Text summary of the resource, for human interpretation
... contained 0..* Resource Contained, inline Resources
... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
.... goal-acceptance S 0..* (Complex) Information about the acceptance and relative priority assigned to the goal by the patient, practitioners and other stake-holders
URL: http://hl7.org/fhir/StructureDefinition/goal-acceptance
.... reasonRejected S 0..1 CodeableConcept The reason the goal was not accepted. Applies only if the status of the goal is rejected
URL: http://hl7.org/fhir/StructureDefinition/goal-reasonRejected
.... related-goal S 0..* (Complex) Establishes a relationship between this goal and other goals. Such as related Milestone Goal.
URL: http://hl7.org/fhir/StructureDefinition/goal-relationship
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... identifier 0..* Identifier External Ids for this goal
... lifecycleStatus ?!SΣ 1..1 code (USCDI) proposed | planned | accepted | active | on-hold | completed | cancelled | entered-in-error | rejected
Binding: GoalLifecycleStatus (required)
... achievementStatus SΣ 0..1 CodeableConcept in-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 Σ 0..* CodeableConcept E.g. Treatment, dietary, behavioral, etc.
Binding: GoalCategory (example): Codes for grouping and sorting goals.


... priority SΣ 0..1 CodeableConcept high-priority | medium-priority | low-priority
Binding: GoalPriority (preferred): The level of importance associated with a goal.

... description SΣ 1..1 CodeableConcept (USCDI) Code or text describing goal
Binding: US Core Goal Codes (extensible): Value set to describe the Goal

... subject SΣ 1..1 Reference(US Core Patient Profile) (USCDI) Who this goal is intended for
... start[x] SΣ 0..1 (USCDI) When goal pursuit begins
Binding: GoalStartEvent (example): Codes describing events that can trigger the initiation of a goal.

.... startDate date S
.... startCodeableConcept CodeableConcept
... target SC 0..* BackboneElement (USCDI) Target outcome for the goal
gol-1: Goal.target.measure is required if Goal.target.detail is populated
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... measure ΣC 0..1 CodeableConcept The 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] ΣC 0..1 The 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.

..... detailQuantity Quantity
..... detailRange Range
..... detailCodeableConcept CodeableConcept
..... detailString string
..... detailBoolean boolean
..... detailInteger integer
..... detailRatio Ratio
.... due[x] SΣ 0..1 (USCDI) Reach goal on or before
..... dueDate date S
..... dueDuration Duration
... statusDate Σ 0..1 date When goal status took effect
... statusReason 0..1 string Reason for current status
... expressedBy SΣ 0..1 Reference(Patient | Practitioner | PractitionerRole | RelatedPerson) Who's responsible for creating Goal?
... addresses S 0..* Reference(Condition | Observation | MedicationStatement | NutritionOrder | ServiceRequest | RiskAssessment) Issues addressed by this goal
... note 0..* Annotation Comments about the goal
... outcomeCode 0..* CodeableConcept What 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 S 0..* Reference(Observation) Observation that resulted from goal

doco Documentation for this format

Terminology Bindings

PathConformanceValueSetURI
Goal.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
http://hl7.org/fhir/ValueSet/languages
from the FHIR Standard
Goal.lifecycleStatusrequiredGoalLifecycleStatus
http://hl7.org/fhir/ValueSet/goal-status
from the FHIR Standard
Goal.achievementStatuspreferredGoalAchievementStatus
http://hl7.org/fhir/ValueSet/goal-achievement
from the FHIR Standard
Goal.categoryexampleGoalCategory
http://hl7.org/fhir/ValueSet/goal-category
from the FHIR Standard
Goal.prioritypreferredGoalPriority
http://hl7.org/fhir/ValueSet/goal-priority
from the FHIR Standard
Goal.descriptionextensibleUSCoreGoalCodes
http://hl7.org/fhir/us/core/ValueSet/us-core-goal-description
Goal.start[x]exampleGoalStartEvent
http://hl7.org/fhir/ValueSet/goal-start-event
from the FHIR Standard
Goal.target.measureexampleLOINCCodes (a valid code from LOINC)
http://hl7.org/fhir/ValueSet/observation-codes
from the FHIR Standard
Goal.target.detail[x]example
Goal.outcomeCodeexampleSNOMEDCTClinicalFindings
http://hl7.org/fhir/ValueSet/clinical-findings
from the FHIR Standard

Constraints

IdGradePath(s)DetailsRequirements
dom-2errorGoalIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3errorGoalIf 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-4errorGoalIf 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-5errorGoalIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6best practiceGoalA resource should have narrative for robust management
: text.`div`.exists()
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()
gol-1errorGoal.targetGoal.target.measure is required if Goal.target.detail is populated
: (detail.exists() and measure.exists()) or detail.exists().not()

 

Other representations of profile: CSV, Excel, Schematron