Example Usage Scenarios:

The following are example usage scenarios for this profile:

• Query for a Patient’s Goals
• Record or update a Patient’s Goals

Mandatory and Must Support Data Elements

The following data-elements must always be present (Mandatory definition) or must be supported if the data is present in the sending system (Must Support definition). They are presented below in a simple human-readable explanation. Profile specific guidance and examples are provided as well. The Formal Views below provides the formal summary, definitions, and terminology requirements.

Each Goal must have:

1. a status
2. text description of the goal
3. a patient

Each Goal must support:

1. target date(s):

Profile specific implementation guidance:

• Free text goals can be used in Goal.description.text when a concept isn’t available or a legacy goal is not mapped to a LOINC or SNOMED concept.
• See the [SDOH] guidance page for more information when exchanging Social Determinants of Health (SDOH) Goals

• Differential Table
• Key Elements Table
• Snapshot Table
• Statistics/References
• All

This structure is derived from Goal

Name	Flags	Card.	Type	Description & Constraints
Goal		0..*	Goal	Describes the intended objective(s) for a patient, group or organization
lifecycleStatus	S	1..1	code	proposed | planned | accepted | active | on-hold | completed | cancelled | entered-in-error | rejected Binding: GoalLifecycleStatus (required)
description	S	1..1	CodeableConcept	Code or text describing goal Binding: US Core Goal Codes (extensible): Value set to describe the Goal
subject	S	1..1	Reference(US Core Patient Profile)	Who this goal is intended for
target	S	0..*	BackboneElement	Target outcome for the goal
due[x]	S	0..1		Reach goal on or before
dueDate			date S
dueDuration			Duration
Documentation for this format

Terminology Bindings (Differential)

Path	Conformance	ValueSet
Goal.lifecycleStatus	required	GoalLifecycleStatus
Goal.description	extensible	USCoreGoalCodes

Name	Flags	Card.	Type	Description & Constraints
Goal		0..*	Goal	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	proposed | planned | accepted | active | on-hold | completed | cancelled | entered-in-error | rejected Binding: GoalLifecycleStatus (required)
description	SΣ	1..1	CodeableConcept	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)	Who this goal is intended for
target	SC	0..*	BackboneElement	Target outcome for the goal
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
due[x]	SΣ	0..1		Reach goal on or before
dueDate			date
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet
Goal.lifecycleStatus	required	GoalLifecycleStatus
Goal.description	extensible	USCoreGoalCodes

Name	Flags	Card.	Type	Description & Constraints
Goal		0..*	Goal	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
language		0..1	code	Language of the resource content Binding: CommonLanguages (preferred): A human language. Additional Bindings Purpose AllLanguages Max Binding
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	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.
category	Σ	0..*	CodeableConcept	E.g. Treatment, dietary, behavioral, etc. Binding: GoalCategory (example): Codes for grouping and sorting goals.
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	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)	Who this goal is intended for
start[x]	Σ	0..1		When goal pursuit begins Binding: GoalStartEvent (example): Codes describing events that can trigger the initiation of a goal.
startDate			date
startCodeableConcept			CodeableConcept
target	SC	0..*	BackboneElement	Target outcome for the goal
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: (unbound) (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		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	Σ	0..1	Reference(Patient | Practitioner | PractitionerRole | RelatedPerson)	Who's responsible for creating Goal?
addresses		0..*	Reference(Condition | Observation | MedicationStatement | NutritionOrder | ServiceRequest | RiskAssessment)	Issues addressed by this goal
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
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet
Goal.language	preferred	CommonLanguages Additional Bindings Purpose AllLanguages Max Binding
Goal.lifecycleStatus	required	GoalLifecycleStatus
Goal.achievementStatus	preferred	GoalAchievementStatus
Goal.category	example	GoalCategory
Goal.priority	preferred	GoalPriority
Goal.description	extensible	USCoreGoalCodes
Goal.start[x]	example	GoalStartEvent
Goal.target.measure	example	LOINCCodes (a valid code from LOINC)
Goal.target.detail[x]	example
Goal.outcomeCode	example	SNOMEDCTClinicalFindings

Differential View

This structure is derived from Goal

Name	Flags	Card.	Type	Description & Constraints
Goal		0..*	Goal	Describes the intended objective(s) for a patient, group or organization
lifecycleStatus	S	1..1	code	proposed | planned | accepted | active | on-hold | completed | cancelled | entered-in-error | rejected Binding: GoalLifecycleStatus (required)
description	S	1..1	CodeableConcept	Code or text describing goal Binding: US Core Goal Codes (extensible): Value set to describe the Goal
subject	S	1..1	Reference(US Core Patient Profile)	Who this goal is intended for
target	S	0..*	BackboneElement	Target outcome for the goal
due[x]	S	0..1		Reach goal on or before
dueDate			date S
dueDuration			Duration
Documentation for this format

Terminology Bindings (Differential)

Path	Conformance	ValueSet
Goal.lifecycleStatus	required	GoalLifecycleStatus
Goal.description	extensible	USCoreGoalCodes

Key Elements View

Name	Flags	Card.	Type	Description & Constraints
Goal		0..*	Goal	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	proposed | planned | accepted | active | on-hold | completed | cancelled | entered-in-error | rejected Binding: GoalLifecycleStatus (required)
description	SΣ	1..1	CodeableConcept	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)	Who this goal is intended for
target	SC	0..*	BackboneElement	Target outcome for the goal
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
due[x]	SΣ	0..1		Reach goal on or before
dueDate			date
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet
Goal.lifecycleStatus	required	GoalLifecycleStatus
Goal.description	extensible	USCoreGoalCodes

Snapshot View

Name	Flags	Card.	Type	Description & Constraints
Goal		0..*	Goal	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
language		0..1	code	Language of the resource content Binding: CommonLanguages (preferred): A human language. Additional Bindings Purpose AllLanguages Max Binding
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	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.
category	Σ	0..*	CodeableConcept	E.g. Treatment, dietary, behavioral, etc. Binding: GoalCategory (example): Codes for grouping and sorting goals.
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	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)	Who this goal is intended for
start[x]	Σ	0..1		When goal pursuit begins Binding: GoalStartEvent (example): Codes describing events that can trigger the initiation of a goal.
startDate			date
startCodeableConcept			CodeableConcept
target	SC	0..*	BackboneElement	Target outcome for the goal
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: (unbound) (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		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	Σ	0..1	Reference(Patient | Practitioner | PractitionerRole | RelatedPerson)	Who's responsible for creating Goal?
addresses		0..*	Reference(Condition | Observation | MedicationStatement | NutritionOrder | ServiceRequest | RiskAssessment)	Issues addressed by this goal
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
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet
Goal.language	preferred	CommonLanguages Additional Bindings Purpose AllLanguages Max Binding
Goal.lifecycleStatus	required	GoalLifecycleStatus
Goal.achievementStatus	preferred	GoalAchievementStatus
Goal.category	example	GoalCategory
Goal.priority	preferred	GoalPriority
Goal.description	extensible	USCoreGoalCodes
Goal.start[x]	example	GoalStartEvent
Goal.target.measure	example	LOINCCodes (a valid code from LOINC)
Goal.target.detail[x]	example
Goal.outcomeCode	example	SNOMEDCTClinicalFindings

This structure is derived from Goal

Summary

Must-Support: 5 elements

Structures

This structure refers to these other structures:

• US Core Patient Profile (http://hl7.org/fhir/us/core/StructureDefinition/us-core-patient)

Quick Start

Below is an overview of the required Server RESTful FHIR interactions for this profile - for example, search and read operations - when supporting the US Core interactions to access this profile’s information (Profile Support + Interaction Support). Note that systems that support only US Core Profiles (Profile Only Support) are not required to support these interactions. See the US Core Server CapabilityStatement for a complete list of supported RESTful interactions for this IG.

• The syntax used to describe the interactions is described here.
• See the General Requirements section for additional rules and expectations when a server requires status parameters.
• See the General Guidance section for additional guidance on searching for multiple patients.

Mandatory Search Parameters:

The following search parameters and search parameter combinations SHALL be supported:

1. SHALL support searching for all goals for a patient using the patient search parameter:

   GET [base]/Goal?patient={Type/}[id]

   Example:

   1. GET [base]/Goal?patient=1137192

   Implementation Notes: Fetches a bundle of all Goal resources for the specified patient (how to search by reference)

Optional Search Parameters:

The following search parameter combinations SHOULD be supported:

1. SHOULD support searching using the combination of the patient and lifecycle-status search parameters:

   GET [base]/Goal?patient={Type/}[id]&lifecycle-status={system|}[code]

   Example:

   1. GET [base]/Goal?patient=1137192&lifecycle-status=active

   Implementation Notes: Fetches a bundle of all Goal resources for the specified patient and lifecycle-status (how to search by reference and how to search by token)

2. SHOULD support searching using the combination of the patient and target-date search parameters:
   • including support for these target-date comparators: gt,lt,ge,le
   • including optional support for AND search on target-date (e.g.target-date=[date]&target-date=[date]]&...)

   GET [base]/Goal?patient={Type/}[id]&target-date={gt|lt|ge|le}[date]{&target-date={gt|lt|ge|le}[date]&...}

   Example:

   1. GET [base]/Goal?patient=1137192&target-date=ge2015-01-14&target-date=le2019-01-14

   Implementation Notes: Fetches a bundle of all Goal resources for the specified patient and target-date (how to search by reference and how to search by date)

3. SHOULD support searching using the combination of the patient and description search parameters:

   GET [base]/Goal?patient={Type/}[id]&description={system|}[code]

   Example:

   1. GET [base]/Goal?patient=1137192&description=http://snomed.info/sct|1078229009

   Implementation Notes: Fetches a bundle of all Goal resources for the specified patient and description (how to search by reference and how to search by token)