Purpose

SDOHCC Goal is generally intended to represent a goal established to address an identified social risk or need (e.g., SDOHCC Condition, SDOHCC Observation Screening Response, SDOHCC Observation Assessment). An SDOHCC ServiceRequest and SDOHCC Procedure can pertain to an SDOHCC Goal. See the Data Modeling Framework for more detail on the relationships between SDOHCC Goal and the other profiles in this IG.

Usage

Goal.description has a binding to US Core Goal Codes (preferred). Goal.description also has additional bindings to SDOH domain-specific value sets (e.g., for Food Insecurity) which are determined by the value selected for Goal.category. When Goal.category is a value from SDOHCC ValueSet SDOH Category (e.g., food-insecurity), Goal.description SHALL be selected from the corresponding domain-specific value set found in Additional Bindings (i.e. Food Insecurity Goals). If more than one value is selected from SDOHCC ValueSet SDOH Category (e.g., food-insecurity and financial-insecurity) for Goal.category, then Goal.description SHALL be selected from at least one of the corresponding domain-specific value sets found in Additional Bindings (e.g. Food Insecurity Goals).

Of note, Gravity Project is continuously developing terminology for new SDOH domains. For new SDOH domains where the Gravity terminology development cycle is in progress, domain-specific value sets may not yet be available in VSAC. If a domain-specific value set is not yet available in VSAC, the Additional Binding is the default binding for the profile element. If a domain-specific value set is available in VSAC but does not yet include all standardized codes identified during the domain’s terminology development cycle, the value set’s VSAC “Description” tab will state, “In progress”. Additional information related to Gravity value sets is provided on the Social Risk Terminology Value Sets page on the Gravity Project Confluence site.

Additionally, some SDOH domains may not yet be represented in SDOHCC ValueSet SDOH Category. In this case, Goal.category: sdoh-category-unspecified can be used so that the Goal instance can still be categorized as SDOH-related. If desired, category.text can also be used to further specify the domain. For example, at the time of publication of this IG, “disability-status” is not yet included in SDOHCC ValueSet SDOH Category. In this case, Goal.category: sdoh-category-unspecified can be used along with category.text: Disability Status. For Goal.category: sdoh-category-unspecified, there will not be domain-specific value sets and Additional Bindings for Goal.description will designate the default binding to US Core Goal Codes (preferred).

For more information on the correlation between Goal.category and the domain-specific value sets in Additional Bindings for Goal.description, see Gravity Project Value Sets.

• 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 SDOH-related objective(s) for a patient.
achievementStatus	S	0..1	CodeableConcept	in-progress | improving | worsening | no-change | achieved | sustaining | not-achieved | no-progress | not-attainable
Slices for category		0..*	CodeableConcept	E.g. Treatment, dietary, behavioral, etc. Slice: Unordered, Open by value:$this
category:SDOH	S	0..*	CodeableConcept	e.g., food-insecurity | transportation-insecurity Binding: SDOHCC ValueSet SDOH Category (required): Codes for high-level SDOH categories.
description		1..1	CodeableConcept	Code or text describing goal Binding: US Core Goal Codes (extensible): Codes providing the details of a particular goal. In many systems, only the text element will be used. Additional Bindings Purpose Usage US Core Goal Codes Preferred Goal.category = digital-access US Core Goal Codes Preferred Goal.category = digital-literacy Less Than High School Education Goals Extensible Goal.category = educational-attainment Elder Abuse Goals Extensible Goal.category = elder-abuse Unemployment Goals Extensible Goal.category = employment-status Financial Insecurity Goals Extensible Goal.category = financial-insecurity Food Insecurity Goals Extensible Goal.category = food-insecurity Health Insurance Coverage Status Goals Extensible Goal.category = health-insurance-coverage-status Homelessness Goals Extensible Goal.category = homelessness Housing Instability Goals Extensible Goal.category = housing-instability Inadequate Housing Goals Extensible Goal.category = inadequate-housing Intimate Partner Violence Goals Extensible Goal.category = intimate-partner-violence Material Hardship Goals Extensible Goal.category = material-hardship Medical Cost Burden Goals Extensible Goal.category = medical-cost-burden Health Literacy Goals Extensible Goal.category = personal-health-literacy Social Connection Goals Extensible Goal.category = social-connection Stress Goals Extensible Goal.category = stress Transportation Insecurity Goals Extensible Goal.category = transportation-insecurity Utility Insecurity Goals Extensible Goal.category = utility-insecurity Veteran Status Goals Extensible Goal.category = veteran-status US Core Goal Codes Preferred Goal.category = sdoh-category-unspecified
subject		1..1	Reference(US Core Patient Profile | Group | Organization)	Who this goal is intended for
target
measure		0..1	CodeableConcept	The parameter whose value is being tracked Binding: LOINCCodes (preferred): Codes to identify the value being tracked, e.g. body weight, blood pressure, or hemoglobin A1c level.
statusDate		0..1	date	When goal status took effect
Slices for addresses		0..*	Reference(Condition | Observation | RiskAssessment)	Issues addressed by this goal Slice: Unordered, Open by profile:resolve()
addresses:SupportedAddresses	S	0..*	Reference(SDOHCC Condition | SDOHCC Observation Screening Response | SDOHCC Observation Assessment)	Issues addressed by this goal
outcomeCode		0..*	CodeableConcept	What result was achieved regarding the goal? Binding: US Core Goal Codes (preferred): The result of the goal; e.g., "Food security", "Has access to a car ".
Slices for outcomeReference		0..*	Reference(Observation)	Observation that resulted from goal Slice: Unordered, Open by profile:resolve()
outcomeReference:SupportedOutcomeReference	S	0..*	Reference(SDOHCC Observation Screening Response | SDOHCC Observation Assessment)	Observation that resulted from goal
Documentation for this format

Terminology Bindings (Differential)

Path	Conformance	ValueSet	URI
Goal.category:SDOH	required	SDOHCCValueSetSDOHCategory http://hl7.org/fhir/us/sdoh-clinicalcare/ValueSet/SDOHCC-ValueSetSDOHCategory from this IG
Goal.description	extensible	USCoreGoalCodes http://hl7.org/fhir/us/core/ValueSet/us-core-goal-description
Goal.target.measure	preferred	LOINCCodes (a valid code from LOINC) http://hl7.org/fhir/ValueSet/observation-codes from the FHIR Standard
Goal.outcomeCode	preferred	USCoreGoalCodes http://hl7.org/fhir/us/core/ValueSet/us-core-goal-description

Name	Flags	Card.	Type	Description & Constraints
Goal		0..*	USCoreGoalProfile	Describes the intended SDOH-related objective(s) for a patient.
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	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.
Slices for category	Σ	0..*	CodeableConcept	E.g. Treatment, dietary, behavioral, etc. Slice: Unordered, Open by value:$this Binding: GoalCategory (example): Codes for grouping and sorting goals.
category:SDOH	SΣ	0..*	CodeableConcept	e.g., food-insecurity | transportation-insecurity Binding: SDOHCC ValueSet SDOH Category (required): Codes for high-level SDOH categories.
description	SΣ	1..1	CodeableConcept	Code or text describing goal Binding: US Core Goal Codes (extensible): Codes providing the details of a particular goal. In many systems, only the text element will be used. Additional Bindings Purpose Usage US Core Goal Codes Preferred Goal.category = digital-access US Core Goal Codes Preferred Goal.category = digital-literacy Less Than High School Education Goals Extensible Goal.category = educational-attainment Elder Abuse Goals Extensible Goal.category = elder-abuse Unemployment Goals Extensible Goal.category = employment-status Financial Insecurity Goals Extensible Goal.category = financial-insecurity Food Insecurity Goals Extensible Goal.category = food-insecurity Health Insurance Coverage Status Goals Extensible Goal.category = health-insurance-coverage-status Homelessness Goals Extensible Goal.category = homelessness Housing Instability Goals Extensible Goal.category = housing-instability Inadequate Housing Goals Extensible Goal.category = inadequate-housing Intimate Partner Violence Goals Extensible Goal.category = intimate-partner-violence Material Hardship Goals Extensible Goal.category = material-hardship Medical Cost Burden Goals Extensible Goal.category = medical-cost-burden Health Literacy Goals Extensible Goal.category = personal-health-literacy Social Connection Goals Extensible Goal.category = social-connection Stress Goals Extensible Goal.category = stress Transportation Insecurity Goals Extensible Goal.category = transportation-insecurity Utility Insecurity Goals Extensible Goal.category = utility-insecurity Veteran Status Goals Extensible Goal.category = veteran-status US Core Goal Codes Preferred Goal.category = sdoh-category-unspecified
subject	SΣ	1..1	Reference(US Core Patient Profile)	Who this goal is intended for
start[x]	SΣ	0..1		When goal pursuit begins Binding: GoalStartEvent (example): Codes describing events that can trigger the initiation of a goal.
startDate			date
target	SC	0..*	BackboneElement	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
measure	ΣC	0..1	CodeableConcept	The parameter whose value is being tracked Binding: LOINCCodes (preferred): Codes to identify the value being tracked, e.g. body weight, blood pressure, or hemoglobin A1c level.
due[x]	SΣ	0..1		Reach goal on or before
dueDate			date
statusDate	Σ	0..1	date	When goal status took effect
Slices for addresses		0..*	Reference(Condition | Observation | RiskAssessment)	Issues addressed by this goal Slice: Unordered, Open by profile:resolve()
addresses:SupportedAddresses	S	0..*	Reference(SDOHCC Condition | SDOHCC Observation Screening Response | SDOHCC Observation Assessment)	Issues addressed by this goal
outcomeCode		0..*	CodeableConcept	What result was achieved regarding the goal? Binding: US Core Goal Codes (preferred): The result of the goal; e.g., "Food security", "Has access to a car ".
Slices for outcomeReference		0..*	Reference(Observation)	Observation that resulted from goal Slice: Unordered, Open by profile:resolve()
outcomeReference:SupportedOutcomeReference	S	0..*	Reference(SDOHCC Observation Screening Response | SDOHCC Observation Assessment)	Observation that resulted from 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	preferred	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.category:SDOH	required	SDOHCCValueSetSDOHCategory http://hl7.org/fhir/us/sdoh-clinicalcare/ValueSet/SDOHCC-ValueSetSDOHCategory from this IG
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	preferred	LOINCCodes (a valid code from LOINC) http://hl7.org/fhir/ValueSet/observation-codes from the FHIR Standard
Goal.outcomeCode	preferred	USCoreGoalCodes http://hl7.org/fhir/us/core/ValueSet/us-core-goal-description

Constraints

Id	Grade	Path(s)	Details	Requirements
dom-2	error	Goal	If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty()
dom-3	error	Goal	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	error	Goal	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	error	Goal	If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty()
dom-6	best practice	Goal	A resource should have narrative for robust management : text.`div`.exists()
ele-1	error	**ALL** elements	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ext-1	error	**ALL** extensions	Must have either extensions or value[x], not both : extension.exists() != value.exists()
gol-1	error	Goal.target	Goal.target.measure is required if Goal.target.detail is populated : (detail.exists() and measure.exists()) or detail.exists().not()

Name	Flags	Card.	Type	Description & Constraints
Goal		0..*	USCoreGoalProfile	Describes the intended SDOH-related objective(s) for a patient.
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	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.
Slices for category	Σ	0..*	CodeableConcept	E.g. Treatment, dietary, behavioral, etc. Slice: Unordered, Open by value:$this Binding: GoalCategory (example): Codes for grouping and sorting goals.
category:SDOH	SΣ	0..*	CodeableConcept	e.g., food-insecurity | transportation-insecurity Binding: SDOHCC ValueSet SDOH Category (required): Codes for high-level SDOH categories.
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	Code or text describing goal Binding: US Core Goal Codes (extensible): Codes providing the details of a particular goal. In many systems, only the text element will be used. Additional Bindings Purpose Usage US Core Goal Codes Preferred Goal.category = digital-access US Core Goal Codes Preferred Goal.category = digital-literacy Less Than High School Education Goals Extensible Goal.category = educational-attainment Elder Abuse Goals Extensible Goal.category = elder-abuse Unemployment Goals Extensible Goal.category = employment-status Financial Insecurity Goals Extensible Goal.category = financial-insecurity Food Insecurity Goals Extensible Goal.category = food-insecurity Health Insurance Coverage Status Goals Extensible Goal.category = health-insurance-coverage-status Homelessness Goals Extensible Goal.category = homelessness Housing Instability Goals Extensible Goal.category = housing-instability Inadequate Housing Goals Extensible Goal.category = inadequate-housing Intimate Partner Violence Goals Extensible Goal.category = intimate-partner-violence Material Hardship Goals Extensible Goal.category = material-hardship Medical Cost Burden Goals Extensible Goal.category = medical-cost-burden Health Literacy Goals Extensible Goal.category = personal-health-literacy Social Connection Goals Extensible Goal.category = social-connection Stress Goals Extensible Goal.category = stress Transportation Insecurity Goals Extensible Goal.category = transportation-insecurity Utility Insecurity Goals Extensible Goal.category = utility-insecurity Veteran Status Goals Extensible Goal.category = veteran-status US Core Goal Codes Preferred Goal.category = sdoh-category-unspecified
subject	SΣ	1..1	Reference(US Core Patient Profile S | Group | Organization)	Who this goal is intended for
start[x]	SΣ	0..1		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	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 (preferred): 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 Description (No ValueSet): (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		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?
Slices for addresses		0..*	Reference(Condition | Observation | RiskAssessment)	Issues addressed by this goal Slice: Unordered, Open by profile:resolve()
addresses:SupportedAddresses	S	0..*	Reference(SDOHCC Condition | SDOHCC Observation Screening Response | SDOHCC Observation Assessment)	Issues addressed by this goal
note		0..*	Annotation	Comments about the goal
outcomeCode		0..*	CodeableConcept	What result was achieved regarding the goal? Binding: US Core Goal Codes (preferred): The result of the goal; e.g., "Food security", "Has access to a car ".
Slices for outcomeReference		0..*	Reference(Observation)	Observation that resulted from goal Slice: Unordered, Open by profile:resolve()
outcomeReference:SupportedOutcomeReference	S	0..*	Reference(SDOHCC Observation Screening Response | SDOHCC Observation Assessment)	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	preferred	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.category:SDOH	required	SDOHCCValueSetSDOHCategory http://hl7.org/fhir/us/sdoh-clinicalcare/ValueSet/SDOHCC-ValueSetSDOHCategory from this IG
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	preferred	LOINCCodes (a valid code from LOINC) http://hl7.org/fhir/ValueSet/observation-codes from the FHIR Standard
Goal.target.detail[x]	example
Goal.outcomeCode	preferred	USCoreGoalCodes http://hl7.org/fhir/us/core/ValueSet/us-core-goal-description

Constraints

Id	Grade	Path(s)	Details	Requirements
dom-2	error	Goal	If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty()
dom-3	error	Goal	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	error	Goal	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	error	Goal	If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty()
dom-6	best practice	Goal	A resource should have narrative for robust management : text.`div`.exists()
ele-1	error	**ALL** elements	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ext-1	error	**ALL** extensions	Must have either extensions or value[x], not both : extension.exists() != value.exists()
gol-1	error	Goal.target	Goal.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

Name	Flags	Card.	Type	Description & Constraints
Goal		0..*	USCoreGoalProfile	Describes the intended SDOH-related objective(s) for a patient.
achievementStatus	S	0..1	CodeableConcept	in-progress | improving | worsening | no-change | achieved | sustaining | not-achieved | no-progress | not-attainable
Slices for category		0..*	CodeableConcept	E.g. Treatment, dietary, behavioral, etc. Slice: Unordered, Open by value:$this
category:SDOH	S	0..*	CodeableConcept	e.g., food-insecurity | transportation-insecurity Binding: SDOHCC ValueSet SDOH Category (required): Codes for high-level SDOH categories.
description		1..1	CodeableConcept	Code or text describing goal Binding: US Core Goal Codes (extensible): Codes providing the details of a particular goal. In many systems, only the text element will be used. Additional Bindings Purpose Usage US Core Goal Codes Preferred Goal.category = digital-access US Core Goal Codes Preferred Goal.category = digital-literacy Less Than High School Education Goals Extensible Goal.category = educational-attainment Elder Abuse Goals Extensible Goal.category = elder-abuse Unemployment Goals Extensible Goal.category = employment-status Financial Insecurity Goals Extensible Goal.category = financial-insecurity Food Insecurity Goals Extensible Goal.category = food-insecurity Health Insurance Coverage Status Goals Extensible Goal.category = health-insurance-coverage-status Homelessness Goals Extensible Goal.category = homelessness Housing Instability Goals Extensible Goal.category = housing-instability Inadequate Housing Goals Extensible Goal.category = inadequate-housing Intimate Partner Violence Goals Extensible Goal.category = intimate-partner-violence Material Hardship Goals Extensible Goal.category = material-hardship Medical Cost Burden Goals Extensible Goal.category = medical-cost-burden Health Literacy Goals Extensible Goal.category = personal-health-literacy Social Connection Goals Extensible Goal.category = social-connection Stress Goals Extensible Goal.category = stress Transportation Insecurity Goals Extensible Goal.category = transportation-insecurity Utility Insecurity Goals Extensible Goal.category = utility-insecurity Veteran Status Goals Extensible Goal.category = veteran-status US Core Goal Codes Preferred Goal.category = sdoh-category-unspecified
subject		1..1	Reference(US Core Patient Profile | Group | Organization)	Who this goal is intended for
target
measure		0..1	CodeableConcept	The parameter whose value is being tracked Binding: LOINCCodes (preferred): Codes to identify the value being tracked, e.g. body weight, blood pressure, or hemoglobin A1c level.
statusDate		0..1	date	When goal status took effect
Slices for addresses		0..*	Reference(Condition | Observation | RiskAssessment)	Issues addressed by this goal Slice: Unordered, Open by profile:resolve()
addresses:SupportedAddresses	S	0..*	Reference(SDOHCC Condition | SDOHCC Observation Screening Response | SDOHCC Observation Assessment)	Issues addressed by this goal
outcomeCode		0..*	CodeableConcept	What result was achieved regarding the goal? Binding: US Core Goal Codes (preferred): The result of the goal; e.g., "Food security", "Has access to a car ".
Slices for outcomeReference		0..*	Reference(Observation)	Observation that resulted from goal Slice: Unordered, Open by profile:resolve()
outcomeReference:SupportedOutcomeReference	S	0..*	Reference(SDOHCC Observation Screening Response | SDOHCC Observation Assessment)	Observation that resulted from goal
Documentation for this format

Terminology Bindings (Differential)

Path	Conformance	ValueSet	URI
Goal.category:SDOH	required	SDOHCCValueSetSDOHCategory http://hl7.org/fhir/us/sdoh-clinicalcare/ValueSet/SDOHCC-ValueSetSDOHCategory from this IG
Goal.description	extensible	USCoreGoalCodes http://hl7.org/fhir/us/core/ValueSet/us-core-goal-description
Goal.target.measure	preferred	LOINCCodes (a valid code from LOINC) http://hl7.org/fhir/ValueSet/observation-codes from the FHIR Standard
Goal.outcomeCode	preferred	USCoreGoalCodes http://hl7.org/fhir/us/core/ValueSet/us-core-goal-description

Key Elements View

Name	Flags	Card.	Type	Description & Constraints
Goal		0..*	USCoreGoalProfile	Describes the intended SDOH-related objective(s) for a patient.
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	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.
Slices for category	Σ	0..*	CodeableConcept	E.g. Treatment, dietary, behavioral, etc. Slice: Unordered, Open by value:$this Binding: GoalCategory (example): Codes for grouping and sorting goals.
category:SDOH	SΣ	0..*	CodeableConcept	e.g., food-insecurity | transportation-insecurity Binding: SDOHCC ValueSet SDOH Category (required): Codes for high-level SDOH categories.
description	SΣ	1..1	CodeableConcept	Code or text describing goal Binding: US Core Goal Codes (extensible): Codes providing the details of a particular goal. In many systems, only the text element will be used. Additional Bindings Purpose Usage US Core Goal Codes Preferred Goal.category = digital-access US Core Goal Codes Preferred Goal.category = digital-literacy Less Than High School Education Goals Extensible Goal.category = educational-attainment Elder Abuse Goals Extensible Goal.category = elder-abuse Unemployment Goals Extensible Goal.category = employment-status Financial Insecurity Goals Extensible Goal.category = financial-insecurity Food Insecurity Goals Extensible Goal.category = food-insecurity Health Insurance Coverage Status Goals Extensible Goal.category = health-insurance-coverage-status Homelessness Goals Extensible Goal.category = homelessness Housing Instability Goals Extensible Goal.category = housing-instability Inadequate Housing Goals Extensible Goal.category = inadequate-housing Intimate Partner Violence Goals Extensible Goal.category = intimate-partner-violence Material Hardship Goals Extensible Goal.category = material-hardship Medical Cost Burden Goals Extensible Goal.category = medical-cost-burden Health Literacy Goals Extensible Goal.category = personal-health-literacy Social Connection Goals Extensible Goal.category = social-connection Stress Goals Extensible Goal.category = stress Transportation Insecurity Goals Extensible Goal.category = transportation-insecurity Utility Insecurity Goals Extensible Goal.category = utility-insecurity Veteran Status Goals Extensible Goal.category = veteran-status US Core Goal Codes Preferred Goal.category = sdoh-category-unspecified
subject	SΣ	1..1	Reference(US Core Patient Profile)	Who this goal is intended for
start[x]	SΣ	0..1		When goal pursuit begins Binding: GoalStartEvent (example): Codes describing events that can trigger the initiation of a goal.
startDate			date
target	SC	0..*	BackboneElement	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
measure	ΣC	0..1	CodeableConcept	The parameter whose value is being tracked Binding: LOINCCodes (preferred): Codes to identify the value being tracked, e.g. body weight, blood pressure, or hemoglobin A1c level.
due[x]	SΣ	0..1		Reach goal on or before
dueDate			date
statusDate	Σ	0..1	date	When goal status took effect
Slices for addresses		0..*	Reference(Condition | Observation | RiskAssessment)	Issues addressed by this goal Slice: Unordered, Open by profile:resolve()
addresses:SupportedAddresses	S	0..*	Reference(SDOHCC Condition | SDOHCC Observation Screening Response | SDOHCC Observation Assessment)	Issues addressed by this goal
outcomeCode		0..*	CodeableConcept	What result was achieved regarding the goal? Binding: US Core Goal Codes (preferred): The result of the goal; e.g., "Food security", "Has access to a car ".
Slices for outcomeReference		0..*	Reference(Observation)	Observation that resulted from goal Slice: Unordered, Open by profile:resolve()
outcomeReference:SupportedOutcomeReference	S	0..*	Reference(SDOHCC Observation Screening Response | SDOHCC Observation Assessment)	Observation that resulted from 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	preferred	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.category:SDOH	required	SDOHCCValueSetSDOHCategory http://hl7.org/fhir/us/sdoh-clinicalcare/ValueSet/SDOHCC-ValueSetSDOHCategory from this IG
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	preferred	LOINCCodes (a valid code from LOINC) http://hl7.org/fhir/ValueSet/observation-codes from the FHIR Standard
Goal.outcomeCode	preferred	USCoreGoalCodes http://hl7.org/fhir/us/core/ValueSet/us-core-goal-description

Constraints

Id	Grade	Path(s)	Details	Requirements
dom-2	error	Goal	If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty()
dom-3	error	Goal	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	error	Goal	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	error	Goal	If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty()
dom-6	best practice	Goal	A resource should have narrative for robust management : text.`div`.exists()
ele-1	error	**ALL** elements	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ext-1	error	**ALL** extensions	Must have either extensions or value[x], not both : extension.exists() != value.exists()
gol-1	error	Goal.target	Goal.target.measure is required if Goal.target.detail is populated : (detail.exists() and measure.exists()) or detail.exists().not()

Snapshot View

Name	Flags	Card.	Type	Description & Constraints
Goal		0..*	USCoreGoalProfile	Describes the intended SDOH-related objective(s) for a patient.
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	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.
Slices for category	Σ	0..*	CodeableConcept	E.g. Treatment, dietary, behavioral, etc. Slice: Unordered, Open by value:$this Binding: GoalCategory (example): Codes for grouping and sorting goals.
category:SDOH	SΣ	0..*	CodeableConcept	e.g., food-insecurity | transportation-insecurity Binding: SDOHCC ValueSet SDOH Category (required): Codes for high-level SDOH categories.
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	Code or text describing goal Binding: US Core Goal Codes (extensible): Codes providing the details of a particular goal. In many systems, only the text element will be used. Additional Bindings Purpose Usage US Core Goal Codes Preferred Goal.category = digital-access US Core Goal Codes Preferred Goal.category = digital-literacy Less Than High School Education Goals Extensible Goal.category = educational-attainment Elder Abuse Goals Extensible Goal.category = elder-abuse Unemployment Goals Extensible Goal.category = employment-status Financial Insecurity Goals Extensible Goal.category = financial-insecurity Food Insecurity Goals Extensible Goal.category = food-insecurity Health Insurance Coverage Status Goals Extensible Goal.category = health-insurance-coverage-status Homelessness Goals Extensible Goal.category = homelessness Housing Instability Goals Extensible Goal.category = housing-instability Inadequate Housing Goals Extensible Goal.category = inadequate-housing Intimate Partner Violence Goals Extensible Goal.category = intimate-partner-violence Material Hardship Goals Extensible Goal.category = material-hardship Medical Cost Burden Goals Extensible Goal.category = medical-cost-burden Health Literacy Goals Extensible Goal.category = personal-health-literacy Social Connection Goals Extensible Goal.category = social-connection Stress Goals Extensible Goal.category = stress Transportation Insecurity Goals Extensible Goal.category = transportation-insecurity Utility Insecurity Goals Extensible Goal.category = utility-insecurity Veteran Status Goals Extensible Goal.category = veteran-status US Core Goal Codes Preferred Goal.category = sdoh-category-unspecified
subject	SΣ	1..1	Reference(US Core Patient Profile S | Group | Organization)	Who this goal is intended for
start[x]	SΣ	0..1		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	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 (preferred): 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 Description (No ValueSet): (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		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?
Slices for addresses		0..*	Reference(Condition | Observation | RiskAssessment)	Issues addressed by this goal Slice: Unordered, Open by profile:resolve()
addresses:SupportedAddresses	S	0..*	Reference(SDOHCC Condition | SDOHCC Observation Screening Response | SDOHCC Observation Assessment)	Issues addressed by this goal
note		0..*	Annotation	Comments about the goal
outcomeCode		0..*	CodeableConcept	What result was achieved regarding the goal? Binding: US Core Goal Codes (preferred): The result of the goal; e.g., "Food security", "Has access to a car ".
Slices for outcomeReference		0..*	Reference(Observation)	Observation that resulted from goal Slice: Unordered, Open by profile:resolve()
outcomeReference:SupportedOutcomeReference	S	0..*	Reference(SDOHCC Observation Screening Response | SDOHCC Observation Assessment)	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	preferred	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.category:SDOH	required	SDOHCCValueSetSDOHCategory http://hl7.org/fhir/us/sdoh-clinicalcare/ValueSet/SDOHCC-ValueSetSDOHCategory from this IG
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	preferred	LOINCCodes (a valid code from LOINC) http://hl7.org/fhir/ValueSet/observation-codes from the FHIR Standard
Goal.target.detail[x]	example
Goal.outcomeCode	preferred	USCoreGoalCodes http://hl7.org/fhir/us/core/ValueSet/us-core-goal-description

Constraints

Id	Grade	Path(s)	Details	Requirements
dom-2	error	Goal	If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty()
dom-3	error	Goal	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	error	Goal	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	error	Goal	If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty()
dom-6	best practice	Goal	A resource should have narrative for robust management : text.`div`.exists()
ele-1	error	**ALL** elements	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ext-1	error	**ALL** extensions	Must have either extensions or value[x], not both : extension.exists() != value.exists()
gol-1	error	Goal.target	Goal.target.measure is required if Goal.target.detail is populated : (detail.exists() and measure.exists()) or detail.exists().not()

This structure is derived from USCoreGoalProfile

Summary

Must-Support: 4 elements

Structures

This structure refers to these other structures:

• SDOHCC Condition (http://hl7.org/fhir/us/sdoh-clinicalcare/StructureDefinition/SDOHCC-Condition)
• SDOHCC Observation Screening Response (http://hl7.org/fhir/us/sdoh-clinicalcare/StructureDefinition/SDOHCC-ObservationScreeningResponse)
• SDOHCC Observation Assessment (http://hl7.org/fhir/us/sdoh-clinicalcare/StructureDefinition/SDOHCC-ObservationAssessment)

Slices

This structure defines the following Slices:

• The element 1 is sliced based on the value of Goal.category
• The element 1 is sliced based on the value of Goal.addresses
• The element 1 is sliced based on the value of Goal.outcomeReference