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Patient Care Work Group Maturity Level : 2   Trial Use Security Category : Patient Compartments : Patient

Detailed Descriptions for the elements in the Goal resource.

Goal
Element Id Goal
Definition

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.

Control Cardinality 1..1 0..*
Type DomainResource
Comments

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

Goal.identifier
Element Id Goal.identifier
Definition

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.

Note This is a business identifer, identifier, not a resource identifier (see discussion )
Control Cardinality 0..*
Type Identifier
Requirements

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.

Comments

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.

Goal.status Goal.lifecycleStatus
Element Id Goal.lifecycleStatus
Definition

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

Control Cardinality 1..1
Terminology Binding GoalStatus GoalLifecycleStatus ( Required )
Type code
Is Modifier true (Reason: This element is labelled as a modifier because it is a status element that contains status entered-in-error which means that the resource should not be treated as valid)
Requirements

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

Summary true
Comments

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

Goal.achievementStatus
Element Id Goal.achievementStatus
Definition

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

Cardinality 0..1
Terminology Binding Goal achievement status ( Preferred )
Type CodeableConcept
Summary true
Goal.category
Element Id Goal.category
Definition

Indicates a category the goal falls within.

Control Cardinality 0..*
Terminology Binding GoalCategory Goal category ( Example )
Type CodeableConcept
Requirements

Allows goals to be filtered and sorted.

Summary true
Goal.continuous
Element Id Goal.continuous
Definition

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

Cardinality 0..1
Type boolean
Requirements

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

Comments

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).

Goal.priority
Element Id Goal.priority
Definition

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

Control Cardinality 0..1
Terminology Binding GoalPriority Goal priority ( Preferred )
Type CodeableConcept
Requirements

Used for sorting and presenting goals.

Summary true
Comments

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".

Goal.description
Element Id Goal.description
Definition

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".

Control Cardinality 1..1
Terminology Binding SNOMED CT Clinical Findings ( Example )
Type CodeableConcept
Requirements

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

Summary true
Comments

If no code is available, use CodeableConcept.text.

Goal.subject
Element Id Goal.subject
Definition

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

Control Cardinality 0..1 1..1
Type Reference ( Patient | Group | Organization )
Patterns Reference(Patient,Group,Organization): Common patterns = Participant
Requirements

Subject is optional to support annonymized reporting.

Summary true
Goal.start[x]
Element Id Goal.start[x]
Definition

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

Control Cardinality 0..1
Terminology Binding GoalStartEvent Goal start event ( Example )
Type date | CodeableConcept
[x] Note See Choice of Data Types for further information about how to use [x]
Requirements

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.

Summary true
Goal.target
Element Id Goal.target
Definition

Indicates what should be done by when.

Control Cardinality 0..1 0..*
Requirements

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.

Comments

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

Invariants
Defined on this element
gol-1 : Rule Goal.target.measure is required if Goal.target.detail is populated ( expression : (detail.exists() and measure.exists()) or detail.exists().not(), xpath: (exists(f:*[starts-with(local-name(.), 'detail')]) and exists(f:measure)) or not(exists(f:*[starts-with(local-name(.), 'detail')]))) detail.exists().not()
Affect this element
Goal.target.measure
Element Id Goal.target.measure
Definition

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

Control Cardinality 0..1
Terminology Binding LOINC Codes ( Example )
Type CodeableConcept
Summary true
Invariants
Affect this element
gol-1 : Rule Goal.target.measure is required if Goal.target.detail is populated ( expression : (detail.exists() and measure.exists()) or detail.exists().not(), xpath: (exists(f:*[starts-with(local-name(.), 'detail')]) and exists(f:measure)) or not(exists(f:*[starts-with(local-name(.), 'detail')]))) detail.exists().not()
Goal.target.detail[x]
Element Id Goal.target.detail[x]
Definition

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.

Control Cardinality 0..1
Terminology Binding GoalTargetDetail :
Type Quantity | Range | CodeableConcept | string | boolean | integer | Ratio
[x] Note See Choice of Data Types for further information about how to use [x]
Summary true
Comments

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.

Invariants
Affect this element
gol-1 : Rule Goal.target.measure is required if Goal.target.detail is populated ( expression : (detail.exists() and measure.exists()) or detail.exists().not(), xpath: (exists(f:*[starts-with(local-name(.), 'detail')]) and exists(f:measure)) or not(exists(f:*[starts-with(local-name(.), 'detail')]))) detail.exists().not()
Goal.target.due[x]
Element Id Goal.target.due[x]
Definition

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

Control Cardinality 0..1
Type date | Duration
[x] Note See Choice of Data Types for further information about how to use [x]
Requirements

Identifies when the goal should be evaluated.

Summary true
Goal.statusDate
Element Id Goal.statusDate
Definition

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

Control Cardinality 0..1
Type date
Summary true
Comments

To see the date for past statuses, query history.

Goal.statusReason
Element Id Goal.statusReason
Definition

Captures the reason for the current status.

Control Cardinality 0..1
Type string
Comments

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

Goal.expressedBy
Element Id Goal.expressedBy
Definition

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

Control Cardinality 0..1
Type Reference ( Patient | Practitioner | PractitionerRole | RelatedPerson )
Patterns Reference(Patient,Practitioner,PractitionerRole,RelatedPerson): Common patterns = Participant
Summary true
Comments

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

Goal.addresses
Element Id Goal.addresses
Definition

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

Control Cardinality 0..*
Type Reference ( Condition | Observation | MedicationStatement MedicationUsage | MedicationRequest | NutritionOrder | ProcedureRequest ServiceRequest | RiskAssessment )
Patterns Reference(Condition,Observation,MedicationUsage,MedicationRequest,NutritionOrder,ServiceRequest,RiskAssessment): No common pattern
Requirements

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

Goal.note
Element Id Goal.note
Definition

Any comments related to the goal.

Control Cardinality 0..*
Type Annotation
Requirements

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

Comments

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

Goal.outcomeCode
Element Id Goal.outcomeCode
Definition

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

Control Cardinality 0..*
Terminology Binding SNOMED CT Clinical Findings ( Example )
Type CodeableConcept
Requirements

Outcome tracking is a key aspect of care planning.

Comments

Note that this should not duplicate the goal status.

Goal.outcomeReference
Element Id Goal.outcomeReference
Definition

Details of what's changed (or not changed).

Control Cardinality 0..*
Type Reference ( Observation )
Requirements

Outcome tracking is a key aspect of care planning.

Comments

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.