Person-Centered Outcomes
0.2.0 - ci-build International flag

Person-Centered Outcomes, published by Mountain Lotus WellBeing LLC. This guide is not an authorized publication; it is the continuous build for version 0.2.0 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/mtnlotus/pco-ig/ and changes regularly. See the Directory of published versions

Resource Profile: Person-Centered Goal

Official URL: http://mtnlotus.com/uv/pco/StructureDefinition/pco-goal-profile Version: 0.2.0
Draft as of 2024-10-25 Computable Name: PCOGoalProfile

Person-centered goal focused on what matters most to an individual. A Person-centered goal SHALL include either a Person-Centered Outcome category, or address a What Matters assessment.

Usage:

Formal Views of Profile Content

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

This structure is derived from USCoreGoalProfile

NameFlagsCard.TypeDescription & Constraintsdoco
.. Goal USCoreGoalProfile(6.1.0)
... Slices for category 0..* CodeableConcept E.g. Treatment, dietary, behavioral, etc.
Slice: Unordered, Open by pattern:$this
.... category:pcoCategory S 0..* CodeableConcept Person-Centered Outcome category
Binding: PCO Categories (required): Note that other codes are permitted, see Required Bindings When Slicing by Value Sets


... start[x] 1..1 date (USCDI) When goal pursuit begins
... expressedBy S 0..1 Reference(US Core Patient Profile(6.1.0) | US Core Practitioner Profile(6.1.0) | US Core RelatedPerson Profile(6.1.0)) Who's responsible for creating Goal?

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSetURI
Goal.category:pcoCategoryrequiredPCOCategoryValueSet
http://mtnlotus.com/uv/pco/ValueSet/pco-category-valueset
from this IG
NameFlagsCard.TypeDescription & Constraintsdoco
.. Goal 0..* USCoreGoalProfile(6.1.0) 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)
.... category:pcoCategory SΣ 0..* CodeableConcept Person-Centered Outcome category
Binding: PCO 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(6.1.0)) (USCDI) Who this goal is intended for
... start[x] SΣ 1..1 date (USCDI) When goal pursuit begins
... target SC 0..* BackboneElement (USCDI) Target outcome for the goal
gol-1: Goal.target.measure is required if Goal.target.detail is populated
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... due[x] SΣ 0..1 (USCDI) Reach goal on or before
..... dueDate date
... expressedBy SΣ 0..1 Reference(US Core Patient Profile(6.1.0) | US Core Practitioner Profile(6.1.0) | US Core RelatedPerson Profile(6.1.0)) Who's responsible for creating Goal?
... addresses S 0..* Reference(What Matters Assessment | US Core Condition Problems and Health Concerns Profile(6.1.0)) What Matters Assessment or Condition

doco Documentation for this format

Terminology Bindings

PathConformanceValueSetURI
Goal.lifecycleStatusrequiredGoalLifecycleStatus
http://hl7.org/fhir/ValueSet/goal-status
from the FHIR Standard
Goal.categoryexampleGoalCategory
http://hl7.org/fhir/ValueSet/goal-category
from the FHIR Standard
Goal.category:pcoCategoryrequiredPCOCategoryValueSet
http://mtnlotus.com/uv/pco/ValueSet/pco-category-valueset
from this IG
Goal.descriptionextensibleUSCoreGoalCodes
http://hl7.org/fhir/us/core/ValueSet/us-core-goal-description

Constraints

IdGradePath(s)DetailsRequirements
dom-2errorGoalIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3errorGoalIf the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource
: contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4errorGoalIf a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated
: contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5errorGoalIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6best practiceGoalA resource should have narrative for robust management
: text.`div`.exists()
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()
gol-1errorGoal.targetGoal.target.measure is required if Goal.target.detail is populated
: (detail.exists() and measure.exists()) or detail.exists().not()
NameFlagsCard.TypeDescription & Constraintsdoco
.. Goal 0..* USCoreGoalProfile(6.1.0) Describes the intended objective(s) for a patient, group or organization
... id Σ 0..1 id Logical id of this artifact
... meta Σ 0..1 Meta Metadata about the resource
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... text 0..1 Narrative Text summary of the resource, for human interpretation
... contained 0..* Resource Contained, inline Resources
... 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 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 Σ 0..* CodeableConcept E.g. Treatment, dietary, behavioral, etc.
Slice: Unordered, Open by pattern:$this
Binding: GoalCategory (example): Codes for grouping and sorting goals.


.... category:pcoCategory SΣ 0..* CodeableConcept Person-Centered Outcome category
Binding: PCO 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(6.1.0)) (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
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 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 (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(6.1.0) | US Core Practitioner Profile(6.1.0) | US Core RelatedPerson Profile(6.1.0)) Who's responsible for creating Goal?
... addresses S 0..* Reference(What Matters Assessment | US Core Condition Problems and Health Concerns Profile(6.1.0)) What Matters Assessment or Condition
... 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

doco Documentation for this format

Terminology Bindings

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

Constraints

IdGradePath(s)DetailsRequirements
dom-2errorGoalIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3errorGoalIf the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource
: contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4errorGoalIf a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated
: contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5errorGoalIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6best practiceGoalA resource should have narrative for robust management
: text.`div`.exists()
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()
gol-1errorGoal.targetGoal.target.measure is required if Goal.target.detail is populated
: (detail.exists() and measure.exists()) or detail.exists().not()

Differential View

This structure is derived from USCoreGoalProfile

NameFlagsCard.TypeDescription & Constraintsdoco
.. Goal USCoreGoalProfile(6.1.0)
... Slices for category 0..* CodeableConcept E.g. Treatment, dietary, behavioral, etc.
Slice: Unordered, Open by pattern:$this
.... category:pcoCategory S 0..* CodeableConcept Person-Centered Outcome category
Binding: PCO Categories (required): Note that other codes are permitted, see Required Bindings When Slicing by Value Sets


... start[x] 1..1 date (USCDI) When goal pursuit begins
... expressedBy S 0..1 Reference(US Core Patient Profile(6.1.0) | US Core Practitioner Profile(6.1.0) | US Core RelatedPerson Profile(6.1.0)) Who's responsible for creating Goal?

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSetURI
Goal.category:pcoCategoryrequiredPCOCategoryValueSet
http://mtnlotus.com/uv/pco/ValueSet/pco-category-valueset
from this IG

Key Elements View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Goal 0..* USCoreGoalProfile(6.1.0) 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)
.... category:pcoCategory SΣ 0..* CodeableConcept Person-Centered Outcome category
Binding: PCO 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(6.1.0)) (USCDI) Who this goal is intended for
... start[x] SΣ 1..1 date (USCDI) When goal pursuit begins
... target SC 0..* BackboneElement (USCDI) Target outcome for the goal
gol-1: Goal.target.measure is required if Goal.target.detail is populated
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... due[x] SΣ 0..1 (USCDI) Reach goal on or before
..... dueDate date
... expressedBy SΣ 0..1 Reference(US Core Patient Profile(6.1.0) | US Core Practitioner Profile(6.1.0) | US Core RelatedPerson Profile(6.1.0)) Who's responsible for creating Goal?
... addresses S 0..* Reference(What Matters Assessment | US Core Condition Problems and Health Concerns Profile(6.1.0)) What Matters Assessment or Condition

doco Documentation for this format

Terminology Bindings

PathConformanceValueSetURI
Goal.lifecycleStatusrequiredGoalLifecycleStatus
http://hl7.org/fhir/ValueSet/goal-status
from the FHIR Standard
Goal.categoryexampleGoalCategory
http://hl7.org/fhir/ValueSet/goal-category
from the FHIR Standard
Goal.category:pcoCategoryrequiredPCOCategoryValueSet
http://mtnlotus.com/uv/pco/ValueSet/pco-category-valueset
from this IG
Goal.descriptionextensibleUSCoreGoalCodes
http://hl7.org/fhir/us/core/ValueSet/us-core-goal-description

Constraints

IdGradePath(s)DetailsRequirements
dom-2errorGoalIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3errorGoalIf the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource
: contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4errorGoalIf a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated
: contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5errorGoalIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6best practiceGoalA resource should have narrative for robust management
: text.`div`.exists()
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()
gol-1errorGoal.targetGoal.target.measure is required if Goal.target.detail is populated
: (detail.exists() and measure.exists()) or detail.exists().not()

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Goal 0..* USCoreGoalProfile(6.1.0) Describes the intended objective(s) for a patient, group or organization
... id Σ 0..1 id Logical id of this artifact
... meta Σ 0..1 Meta Metadata about the resource
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... text 0..1 Narrative Text summary of the resource, for human interpretation
... contained 0..* Resource Contained, inline Resources
... 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 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 Σ 0..* CodeableConcept E.g. Treatment, dietary, behavioral, etc.
Slice: Unordered, Open by pattern:$this
Binding: GoalCategory (example): Codes for grouping and sorting goals.


.... category:pcoCategory SΣ 0..* CodeableConcept Person-Centered Outcome category
Binding: PCO 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(6.1.0)) (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
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 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 (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(6.1.0) | US Core Practitioner Profile(6.1.0) | US Core RelatedPerson Profile(6.1.0)) Who's responsible for creating Goal?
... addresses S 0..* Reference(What Matters Assessment | US Core Condition Problems and Health Concerns Profile(6.1.0)) What Matters Assessment or Condition
... 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

doco Documentation for this format

Terminology Bindings

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

Constraints

IdGradePath(s)DetailsRequirements
dom-2errorGoalIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3errorGoalIf the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource
: contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4errorGoalIf a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated
: contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5errorGoalIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6best practiceGoalA resource should have narrative for robust management
: text.`div`.exists()
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()
gol-1errorGoal.targetGoal.target.measure is required if Goal.target.detail is populated
: (detail.exists() and measure.exists()) or detail.exists().not()

 

Other representations of profile: CSV, Excel, Schematron