Goal Attainment Scaling (GAS) in healthcare, measures the extent to which individuals achieve specific goals or objectives. It allows for the quantification and evaluation of progress toward individualized goals, particularly in areas where traditional outcome measures may be insufficient. GAS involves collaboratively setting goals with the individual and assigning numerical scales to each goal to represent different levels of achievement. This approach provides a more nuanced and tailored way to assess progress and outcomes, taking into account the unique circumstances and aspirations of the individual.

For goal attainment scaling, to achieve a goal, the patient must have achieved their Realistic Goal (0) or better [Better Than Expected (+1) or Much Better Than Expected(+2)] by their follow-up visit. A patient's goal with GAS might be defined as shown below. See example FHIR resources for an illustration of how goal extensions are used to represent GAS levels.

Example Goal.description: "Walk 15 minutes 2x/week for 3 months to improve mobility"

Mandatory and Must Support Data Elements

This Person-Centered GAS Goal Profile inherits shared definitions from the PCO Goal Profile; refer to it for scope and usage guidance. It sets minimum expectations for all person-centered Goal resources. Only added constraints are listed here.

Each Goal must support:

1. goal attainment scaling extensions
2. target measure code for 'Goal attainment scale'

Profile Specific Implementation Guidance:

• *Although the extensions and target measure are both marked as Must Support, the server system is not required to support both, but SHALL support at least one of these elements. A client application SHALL support both elements. These elements enable quality measures and other applications to determine that this Goal should have its progress and achievement tracked using GAS.

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

Name	Flags	Card.	Type	Description & Constraints    Filter: Bindings Constraints Obligations
Goal		0..*	PCOGoalProfile	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
extension:gas-scaling	S	0..5	(Complex)	Goal Attainment Scaling Extension URL: http://hl7.org/fhir/us/pco/StructureDefinition/pco-goal-attainment-scaling
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)
Slices for category	SΣ	0..*	CodeableConcept	E.g. Treatment, dietary, behavioral, etc. Slice: Unordered, Open by value:$this Binding: GoalCategory (example): Codes for grouping and sorting goals.
category:pco	SΣ	0..1	CodeableConcept	Person-Centered resource category Binding: Person-Centered Categories (required)
category:goal-domain	SΣ	0..*	CodeableConcept	Person-Centered Outcome goal domain category Binding: PCO Goal Domain Categories (required): Note that other codes are permitted, see Required Bindings When Slicing by Value Sets
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	1..1	date S	(USCDI) When goal pursuit begins
target	SC	0..*	BackboneElement	(USCDI) Target outcome for the goal Constraints: gol-1
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
measure	SΣC	0..1	CodeableConcept	Goal attainment scale - Reported Binding: LOINCCodes (example): Codes to identify the value being tracked, e.g. body weight, blood pressure, or hemoglobin A1c level. Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (Complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://loinc.org
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 107332-9
display		0..1	string	Representation defined by the system
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
due[x]	SΣ	0..1		(USCDI) Reach goal on or before
dueDate			date S
dueDuration			Duration
expressedBy	SΣ	0..1	Reference(US Core Patient Profile | US Core Practitioner Profile | US Core RelatedPerson Profile)	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(What Matters Assessment)	What Matters Assessment or Priority
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet / Code	URI
Goal.lifecycleStatus	required	GoalLifecycleStatus http://hl7.org/fhir/ValueSet/goal-status From the FHIR Standard
Goal.category	example	GoalCategory http://hl7.org/fhir/ValueSet/goal-category From the FHIR Standard
Goal.category:pco	required	PCOCategories http://hl7.org/fhir/us/pco/ValueSet/pco-categories From this IG
Goal.category:goal-domain	required	PCOGoalDomainCategories http://hl7.org/fhir/us/pco/ValueSet/pco-goal-domain-categories From this IG
Goal.description	extensible	USCoreGoalCodes http://hl7.org/fhir/us/core/ValueSet/us-core-goal-description
Goal.target.measure	example	Pattern Value: LOINC Code 107332-9 http://hl7.org/fhir/ValueSet/observation-codes From the FHIR Standard

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 PCOGoalProfile

Name	Flags	Card.	Type	Description & Constraints    Filter: Bindings Constraints Obligations
Goal		0..*	PCOGoalProfile	Describes the intended objective(s) for a patient, group or organization
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
extension:gas-scaling	S	0..5	(Complex)	Goal Attainment Scaling Extension URL: http://hl7.org/fhir/us/pco/StructureDefinition/pco-goal-attainment-scaling
target
measure	S	0..1	CodeableConcept	Goal attainment scale - Reported Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (Complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://loinc.org
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 107332-9
Documentation for this format

Name	Flags	Card.	Type	Description & Constraints    Filter: Bindings Constraints Obligations
Goal		0..*	PCOGoalProfile	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 This profile does not constrain the narrative in regard to content, language, or traceability to data elements
contained		0..*	Resource	Contained, inline Resources
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
extension:gas-scaling	S	0..5	(Complex)	Goal Attainment Scaling Extension URL: http://hl7.org/fhir/us/pco/StructureDefinition/pco-goal-attainment-scaling
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	Σ	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	SΣ	0..*	CodeableConcept	E.g. Treatment, dietary, behavioral, etc. Slice: Unordered, Open by value:$this Binding: GoalCategory (example): Codes for grouping and sorting goals.
category:pco	SΣ	0..1	CodeableConcept	Person-Centered resource category Binding: Person-Centered Categories (required)
category:goal-domain	SΣ	0..*	CodeableConcept	Person-Centered Outcome goal domain category Binding: PCO Goal Domain Categories (required): Note that other codes are permitted, see Required Bindings When Slicing by Value Sets
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	1..1	date S	(USCDI) When goal pursuit begins
target	SC	0..*	BackboneElement	(USCDI) Target outcome for the goal Constraints: gol-1
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	SΣC	0..1	CodeableConcept	Goal attainment scale - Reported Binding: LOINCCodes (example): Codes to identify the value being tracked, e.g. body weight, blood pressure, or hemoglobin A1c level. Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (Complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://loinc.org
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 107332-9
display		0..1	string	Representation defined by the system
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
detail[x]	ΣC	0..1		The target value to be achieved Binding Description: (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(US Core Patient Profile | US Core Practitioner Profile | US Core RelatedPerson Profile)	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(What Matters Assessment)	What Matters Assessment or Priority
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		0..*	Reference(Observation)	Observation that resulted from goal
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet / Code	URI
Goal.language	preferred	CommonLanguages http://hl7.org/fhir/ValueSet/languages From the FHIR Standard Additional Bindings Purpose AllLanguages Max Binding
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:pco	required	PCOCategories http://hl7.org/fhir/us/pco/ValueSet/pco-categories From this IG
Goal.category:goal-domain	required	PCOGoalDomainCategories http://hl7.org/fhir/us/pco/ValueSet/pco-goal-domain-categories 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.target.measure	example	Pattern Value: LOINC Code 107332-9 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

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()

Key Elements View

Name	Flags	Card.	Type	Description & Constraints    Filter: Bindings Constraints Obligations
Goal		0..*	PCOGoalProfile	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
extension:gas-scaling	S	0..5	(Complex)	Goal Attainment Scaling Extension URL: http://hl7.org/fhir/us/pco/StructureDefinition/pco-goal-attainment-scaling
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)
Slices for category	SΣ	0..*	CodeableConcept	E.g. Treatment, dietary, behavioral, etc. Slice: Unordered, Open by value:$this Binding: GoalCategory (example): Codes for grouping and sorting goals.
category:pco	SΣ	0..1	CodeableConcept	Person-Centered resource category Binding: Person-Centered Categories (required)
category:goal-domain	SΣ	0..*	CodeableConcept	Person-Centered Outcome goal domain category Binding: PCO Goal Domain Categories (required): Note that other codes are permitted, see Required Bindings When Slicing by Value Sets
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	1..1	date S	(USCDI) When goal pursuit begins
target	SC	0..*	BackboneElement	(USCDI) Target outcome for the goal Constraints: gol-1
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
measure	SΣC	0..1	CodeableConcept	Goal attainment scale - Reported Binding: LOINCCodes (example): Codes to identify the value being tracked, e.g. body weight, blood pressure, or hemoglobin A1c level. Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (Complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://loinc.org
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 107332-9
display		0..1	string	Representation defined by the system
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
due[x]	SΣ	0..1		(USCDI) Reach goal on or before
dueDate			date S
dueDuration			Duration
expressedBy	SΣ	0..1	Reference(US Core Patient Profile | US Core Practitioner Profile | US Core RelatedPerson Profile)	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(What Matters Assessment)	What Matters Assessment or Priority
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet / Code	URI
Goal.lifecycleStatus	required	GoalLifecycleStatus http://hl7.org/fhir/ValueSet/goal-status From the FHIR Standard
Goal.category	example	GoalCategory http://hl7.org/fhir/ValueSet/goal-category From the FHIR Standard
Goal.category:pco	required	PCOCategories http://hl7.org/fhir/us/pco/ValueSet/pco-categories From this IG
Goal.category:goal-domain	required	PCOGoalDomainCategories http://hl7.org/fhir/us/pco/ValueSet/pco-goal-domain-categories From this IG
Goal.description	extensible	USCoreGoalCodes http://hl7.org/fhir/us/core/ValueSet/us-core-goal-description
Goal.target.measure	example	Pattern Value: LOINC Code 107332-9 http://hl7.org/fhir/ValueSet/observation-codes From the FHIR Standard

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 PCOGoalProfile

Name	Flags	Card.	Type	Description & Constraints    Filter: Bindings Constraints Obligations
Goal		0..*	PCOGoalProfile	Describes the intended objective(s) for a patient, group or organization
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
extension:gas-scaling	S	0..5	(Complex)	Goal Attainment Scaling Extension URL: http://hl7.org/fhir/us/pco/StructureDefinition/pco-goal-attainment-scaling
target
measure	S	0..1	CodeableConcept	Goal attainment scale - Reported Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (Complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://loinc.org
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 107332-9
Documentation for this format

Snapshot View

Name	Flags	Card.	Type	Description & Constraints    Filter: Bindings Constraints Obligations
Goal		0..*	PCOGoalProfile	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 This profile does not constrain the narrative in regard to content, language, or traceability to data elements
contained		0..*	Resource	Contained, inline Resources
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
extension:gas-scaling	S	0..5	(Complex)	Goal Attainment Scaling Extension URL: http://hl7.org/fhir/us/pco/StructureDefinition/pco-goal-attainment-scaling
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	Σ	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	SΣ	0..*	CodeableConcept	E.g. Treatment, dietary, behavioral, etc. Slice: Unordered, Open by value:$this Binding: GoalCategory (example): Codes for grouping and sorting goals.
category:pco	SΣ	0..1	CodeableConcept	Person-Centered resource category Binding: Person-Centered Categories (required)
category:goal-domain	SΣ	0..*	CodeableConcept	Person-Centered Outcome goal domain category Binding: PCO Goal Domain Categories (required): Note that other codes are permitted, see Required Bindings When Slicing by Value Sets
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	1..1	date S	(USCDI) When goal pursuit begins
target	SC	0..*	BackboneElement	(USCDI) Target outcome for the goal Constraints: gol-1
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	SΣC	0..1	CodeableConcept	Goal attainment scale - Reported Binding: LOINCCodes (example): Codes to identify the value being tracked, e.g. body weight, blood pressure, or hemoglobin A1c level. Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (Complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://loinc.org
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 107332-9
display		0..1	string	Representation defined by the system
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
detail[x]	ΣC	0..1		The target value to be achieved Binding Description: (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(US Core Patient Profile | US Core Practitioner Profile | US Core RelatedPerson Profile)	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(What Matters Assessment)	What Matters Assessment or Priority
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		0..*	Reference(Observation)	Observation that resulted from goal
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet / Code	URI
Goal.language	preferred	CommonLanguages http://hl7.org/fhir/ValueSet/languages From the FHIR Standard Additional Bindings Purpose AllLanguages Max Binding
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:pco	required	PCOCategories http://hl7.org/fhir/us/pco/ValueSet/pco-categories From this IG
Goal.category:goal-domain	required	PCOGoalDomainCategories http://hl7.org/fhir/us/pco/ValueSet/pco-goal-domain-categories 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.target.measure	example	Pattern Value: LOINC Code 107332-9 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

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 PCOGoalProfile

Summary

Must-Support: 2 elements

Extensions

This structure refers to these extensions:

• http://hl7.org/fhir/us/pco/StructureDefinition/pco-goal-attainment-scaling

Maturity: 2