PACIO Personal Functioning and Engagement Implementation Guide, published by HL7 International / Patient Care. This guide is not an authorized publication; it is the continuous build for version 2.0.0-ballot built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/fhir-pacio-pfe/ and changes regularly. See the Directory of published versions

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• Detailed Descriptions
• Mappings
• Examples
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Resource Profile: Personal Functioning and Engagement Goal Profile

An exchange of post-acute care goal for a patient. This profile is used for exchanging a personal functioning and engagement goal.

Usage:

• Examples for this Resource Profile: Goal/PFEIG-Goal-DressingGoal, Goal/PFEIG-Goal-StandingGoal and Goal/PFEIG-Goal-WalkingGoal

Formal Views of Profile Content

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

• Differential Table
• Key Elements Table
• Snapshot Table
• Statistics/References
• All

This structure is derived from USCoreGoalProfile

Name	Flags	Card.	Type	Description & Constraints
Goal		0..*	USCoreGoalProfile	Describes the intended objective(s) for a patient, group or organization
achievementStatus	S	0..1	CodeableConcept	in-progress | improving | worsening | no-change | achieved | sustaining | not-achieved | no-progress | not-attainable Binding: GoalAchievementStatus (extensible)
addresses	S	0..*	Reference(Condition | Observation | MedicationStatement | NutritionOrder | ServiceRequest | RiskAssessment)	Issues addressed by this goal
note	S	0..*	Annotation	Comments about the goal
Documentation for this format

Terminology Bindings (Differential)

Path	Conformance	ValueSet	URI
Goal.achievementStatus	extensible	GoalAchievementStatus http://hl7.org/fhir/ValueSet/goal-achievement from the FHIR Standard

Name	Flags	Card.	Type	Description & Constraints
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
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
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 (extensible)
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
addresses	S	0..*	Reference(Condition | Observation | MedicationStatement | NutritionOrder | ServiceRequest | RiskAssessment)	Issues addressed by this goal
note	S	0..*	Annotation	Comments about the goal
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet	URI
Goal.lifecycleStatus	required	GoalLifecycleStatus http://hl7.org/fhir/ValueSet/goal-status from the FHIR Standard
Goal.achievementStatus	extensible	GoalAchievementStatus http://hl7.org/fhir/ValueSet/goal-achievement from the FHIR Standard
Goal.description	extensible	USCoreGoalCodes http://hl7.org/fhir/us/core/ValueSet/us-core-goal-description
Goal.start[x]	example	GoalStartEvent http://hl7.org/fhir/ValueSet/goal-start-event from the FHIR Standard

Name	Flags	Card.	Type	Description & Constraints
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
language		0..1	code	Language of the resource content Binding: CommonLanguages (preferred): A human language. Additional Bindings Purpose AllLanguages Max Binding
text		0..1	Narrative	Text summary of the resource, for human interpretation
contained		0..*	Resource	Contained, inline Resources
extension		0..*	Extension	Additional content defined by implementations
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 (extensible)
category	Σ	0..*	CodeableConcept	E.g. Treatment, dietary, behavioral, etc. Binding: GoalCategory (example): Codes for grouping and sorting goals.
priority	Σ	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	Σ	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	S	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		0..*	Reference(Observation)	Observation that resulted from goal
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet	URI
Goal.language	preferred	CommonLanguages Additional Bindings Purpose AllLanguages Max Binding http://hl7.org/fhir/ValueSet/languages from the FHIR Standard
Goal.lifecycleStatus	required	GoalLifecycleStatus http://hl7.org/fhir/ValueSet/goal-status from the FHIR Standard
Goal.achievementStatus	extensible	GoalAchievementStatus http://hl7.org/fhir/ValueSet/goal-achievement from the FHIR Standard
Goal.category	example	GoalCategory http://hl7.org/fhir/ValueSet/goal-category from the FHIR Standard
Goal.priority	preferred	GoalPriority http://hl7.org/fhir/ValueSet/goal-priority from the FHIR Standard
Goal.description	extensible	USCoreGoalCodes http://hl7.org/fhir/us/core/ValueSet/us-core-goal-description
Goal.start[x]	example	GoalStartEvent http://hl7.org/fhir/ValueSet/goal-start-event from the FHIR Standard
Goal.target.measure	example	LOINCCodes (a valid code from LOINC) http://hl7.org/fhir/ValueSet/observation-codes from the FHIR Standard
Goal.target.detail[x]	example
Goal.outcomeCode	example	SNOMEDCTClinicalFindings http://hl7.org/fhir/ValueSet/clinical-findings from the FHIR Standard

This structure is derived from USCoreGoalProfile

Summary

Must-Support: 3 elements

Differential View

This structure is derived from USCoreGoalProfile

Name	Flags	Card.	Type	Description & Constraints
Goal		0..*	USCoreGoalProfile	Describes the intended objective(s) for a patient, group or organization
achievementStatus	S	0..1	CodeableConcept	in-progress | improving | worsening | no-change | achieved | sustaining | not-achieved | no-progress | not-attainable Binding: GoalAchievementStatus (extensible)
addresses	S	0..*	Reference(Condition | Observation | MedicationStatement | NutritionOrder | ServiceRequest | RiskAssessment)	Issues addressed by this goal
note	S	0..*	Annotation	Comments about the goal
Documentation for this format

Terminology Bindings (Differential)

Path	Conformance	ValueSet	URI
Goal.achievementStatus	extensible	GoalAchievementStatus http://hl7.org/fhir/ValueSet/goal-achievement from the FHIR Standard

Key Elements View

Name	Flags	Card.	Type	Description & Constraints
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
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
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 (extensible)
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
addresses	S	0..*	Reference(Condition | Observation | MedicationStatement | NutritionOrder | ServiceRequest | RiskAssessment)	Issues addressed by this goal
note	S	0..*	Annotation	Comments about the goal
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet	URI
Goal.lifecycleStatus	required	GoalLifecycleStatus http://hl7.org/fhir/ValueSet/goal-status from the FHIR Standard
Goal.achievementStatus	extensible	GoalAchievementStatus http://hl7.org/fhir/ValueSet/goal-achievement from the FHIR Standard
Goal.description	extensible	USCoreGoalCodes http://hl7.org/fhir/us/core/ValueSet/us-core-goal-description
Goal.start[x]	example	GoalStartEvent http://hl7.org/fhir/ValueSet/goal-start-event from the FHIR Standard

Snapshot View

Name	Flags	Card.	Type	Description & Constraints
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
language		0..1	code	Language of the resource content Binding: CommonLanguages (preferred): A human language. Additional Bindings Purpose AllLanguages Max Binding
text		0..1	Narrative	Text summary of the resource, for human interpretation
contained		0..*	Resource	Contained, inline Resources
extension		0..*	Extension	Additional content defined by implementations
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 (extensible)
category	Σ	0..*	CodeableConcept	E.g. Treatment, dietary, behavioral, etc. Binding: GoalCategory (example): Codes for grouping and sorting goals.
priority	Σ	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	Σ	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	S	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		0..*	Reference(Observation)	Observation that resulted from goal
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet	URI
Goal.language	preferred	CommonLanguages Additional Bindings Purpose AllLanguages Max Binding http://hl7.org/fhir/ValueSet/languages from the FHIR Standard
Goal.lifecycleStatus	required	GoalLifecycleStatus http://hl7.org/fhir/ValueSet/goal-status from the FHIR Standard
Goal.achievementStatus	extensible	GoalAchievementStatus http://hl7.org/fhir/ValueSet/goal-achievement from the FHIR Standard
Goal.category	example	GoalCategory http://hl7.org/fhir/ValueSet/goal-category from the FHIR Standard
Goal.priority	preferred	GoalPriority http://hl7.org/fhir/ValueSet/goal-priority from the FHIR Standard
Goal.description	extensible	USCoreGoalCodes http://hl7.org/fhir/us/core/ValueSet/us-core-goal-description
Goal.start[x]	example	GoalStartEvent http://hl7.org/fhir/ValueSet/goal-start-event from the FHIR Standard
Goal.target.measure	example	LOINCCodes (a valid code from LOINC) http://hl7.org/fhir/ValueSet/observation-codes from the FHIR Standard
Goal.target.detail[x]	example
Goal.outcomeCode	example	SNOMEDCTClinicalFindings http://hl7.org/fhir/ValueSet/clinical-findings from the FHIR Standard

This structure is derived from USCoreGoalProfile

Summary

Must-Support: 3 elements

Other representations of profile: CSV, Excel, Schematron