Describes the intended objective(s) of patient care, for example, weight loss, restoring an activity of daily living, etc.

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

This records identifiers associated with this care plan that are defined by business processed and/ or used to refer to it when a direct URL reference to the resource itself is not appropriate (e.g. in CDA documents, or in written / printed documentation).

Need to allow connection to a wider workflow.

Identifies the patient/subject whose intended care is described by the plan.

Goals are associated with a patient.

Indicates when the goal is intended to be reached.

Identifies when the goal should be evaluated.

Human-readable description of a specific desired objective of care.

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

Indicates whether the goal has been reached and is still considered relevant.

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

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

To see the date for past statuses, query history.

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

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

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 where the goal was deepmed to be cancelled or achieved.

Outcome tracking is a key aspect of care planning.

Note that this should not duplicate the goal status.

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