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 identifiers associated with this care plan that are defined by business processes 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, 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 either the date or the duration after start by which the goal should be met.

Identifies when the goal should be evaluated.

Indicates a category the goal falls within.

Allows goals to be filtered and sorted.

Code and/or human-readable description of a specific desired objective of care.

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

If no code is available, use CodeableConcept.text.

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.

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 for establishing the goal, not necessarily who recorded it. (For that, use the Provenance resource.).

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".

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 deemed 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).