Describes the intended objective(s) for a patient, group or organization care, for example, weight loss, restoring an activity of daily living, obtaining herd immunity via immunization, meeting a process improvement objective, etc.

Goal can be achieving a particular change or merely maintaining a current state or even slowing a decline.

This records Business identifiers associated with assigned to this care plan that are defined goal by business processes and/or used to refer to it when a direct URL reference to the performer or other systems which remain constant as the resource itself is not appropriate (e.g. in CDA documents, or in written / printed documentation). updated and propagates from server to server.

Need to allow connection Allows identification of the goal as it is known by various participating systems and in a way that remains consistent across servers.

This is a business identifier, not a resource identifier (see discussion ). It is best practice for the identifier to only appear on a wider workflow. single resource instance, however business practices may occasionally dictate that multiple resource instances with the same identifier can exist - possibly even with different resource types. For example, multiple Patient and a Person resource instance might share the same social insurance number.

Indicates whether The state of the goal has been reached and is still considered relevant. throughout its lifecycle.

Allows measuring outcome and knowing whether goal needs to be further tracked.

This element is labeled as a modifier because the status lifecycleStatus contains codes that mark the resource as not currently valid.

Describes the progression, or lack thereof, towards the goal against the target.

Indicates a category the goal falls within.

Allows goals to be filtered and sorted.

After meeting the goal, ongoing activity is needed to sustain the goal objective.

Allows for a system to programmatically update achievementStatus upon finding evidence the goal has been met.

For example, getting a yellow fever vaccination for a planned trip is a goal that is designed to be completed (continuous = false). A goal to sustain HbA1c levels would not be a one-time goal (continuous = true).

Identifies the mutually agreed level of importance associated with reaching/sustaining the goal.

Used for sorting and presenting goals.

Extensions are available to track priorities as established by each participant (i.e. Priority from the patient's perspective, different practitioners' perspectives, family member's perspectives)

The ordinal extension on Coding can be used to convey a numerically comparable ranking to priority. (Keep in mind that different coding systems may use a "low value=important".

Human-readable and/or coded description of a specific desired objective of care, such as "control blood pressure" or "negotiate an obstacle course" or "dance with child at wedding".

Without a description of what's trying to be achieved, element has no purpose.

If no code is available, use CodeableConcept.text.

Identifies the patient, group or organization for whom the goal is being established.

Subject is optional to support annonymized reporting.

The date or event after which the goal should begin being pursued.

Goals can be established prior to there being an intention to start pursuing them; e.g. Goals for post-surgical recovery established prior to surgery.

Indicates what should be done by when.

Allows the progress of the goal to be monitored against an observation or due date. Target is 0..* to support Observations with multiple components, such as blood pressure goals with both a systolic and diastolic target.

When multiple targets are present for a single goal instance, all targets must be met for the overall goal to be met.

The parameter whose value is being tracked, e.g. body weight, blood pressure, or hemoglobin A1c level.

The target value of the focus to be achieved to signify the fulfillment of the goal, e.g. 150 pounds, 7.0%. Either the high or low or both values of the range can be specified. When a low value is missing, it indicates that the goal is achieved at any focus value at or below the high value. Similarly, if the high value is missing, it indicates that the goal is achieved at any focus value at or above the low value.

A CodeableConcept with just a text would be used instead of a string if the field was usually coded, or if the type associated with the Goal.target.measure defines a coded value.

Indicates either the date or the duration after start by which the goal should be met.

Identifies when the goal should be evaluated.

Identifies when the current status. I.e. When initially created, when achieved, when cancelled, etc.

To see the date for past statuses, query history.

Captures the reason for the current status.

This will typically be captured for statuses such as rejected, on-hold or cancelled, but could be present for others.

Indicates whose goal this is - patient goal, practitioner goal, etc.

This is the individual reponsible responsible for establishing the goal, not necessarily who recorded it. (For that, use the Provenance resource.).

The identified conditions and other health record elements that are intended to be addressed by the goal.

Allows specific goals to explicitly linked to the concerns they're dealing with - makes the goal more understandable.

Any comments related to the goal.

There's a need to capture information about the goal that doesn't actually describe the goal.

May be used for progress notes, concerns or other related information that doesn't actually describe the goal itself.

Identifies the change (or lack of change) at the point when the status of the goal is assessed.

Outcome tracking is a key aspect of care planning.

Note that this should not duplicate the goal status. Goal.outcomeReference Definition Details of what's changed (or not changed). Control 0..* Type Reference ( Observation ) Requirements Outcome tracking is a key aspect of care planning. Comments status; The goal outcome is independent of the outcome of the related activities. For example, if the Goal is to achieve a target body weight of 150 lb and a care plan activity is defined to diet, then the care plan’s plan’s activity outcome could be calories consumed whereas goal outcome is an observation for the actual body weight measured.