This page is part of the MCC eCare Plan Implementation Guide (v1.0.0-ballot: STU 1 Ballot 1) based on FHIR R4. . For a full list of available versions, see the Directory of published versions 
: MCC Goal Example - Normal Hypertension - JSON Representation
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{
"resourceType" : "Goal",
"id" : "HPT-WNL",
"meta" : {
"versionId" : "5",
"lastUpdated" : "2022-06-02T23:34:46.692+00:00",
"source" : "#2FWI9BsC94EqeXTg",
"profile" : [
"http://hl7.org/fhir/us/mcc/StructureDefinition/MCCGoal"
]
},
"text" : {
"status" : "extensions",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p><b>Generated Narrative: Goal</b><a name=\"HPT-WNL\"> </a></p><div style=\"display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%\"><p style=\"margin-bottom: 0px\">Resource Goal "HPT-WNL" Version "5" Updated "2022-06-02 23:34:46+0000" </p><p style=\"margin-bottom: 0px\">Information Source: #2FWI9BsC94EqeXTg!</p><p style=\"margin-bottom: 0px\">Profile: <a href=\"StructureDefinition-MCCGoal.html\">Multiple Chronic Condition Care Plan Goal</a></p></div><blockquote><p><b>Goal acceptance</b></p><p><b>value</b>: <a href=\"Patient-cc-pat-pnoelle.html\">Patient/cc-pat-pnoelle</a> " NOELLE"</p><p><b>value</b>: agree</p><p><b>value</b>: High Priority <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/3.1.0/CodeSystem-goal-priority.html\">Goal priority</a>#high-priority)</span></p></blockquote><blockquote><p><b>Goal acceptance</b></p><p><b>value</b>: <a href=\"Practitioner-practitionerMCC-3.html\">Practitioner/practitionerMCC-3</a> " PRIMARY"</p><p><b>value</b>: agree</p><p><b>value</b>: High Priority <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/3.1.0/CodeSystem-goal-priority.html\">Goal priority</a>#high-priority)</span></p></blockquote><blockquote><p><b>related goal</b></p><p><b>value</b>: This goal relates to the Weight loss goal <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/3.1.0/CodeSystem-goal-relationship-type.html\">GoalRelationshipType</a>#other)</span></p><p><b>value</b>: <a href=\"Goal-WGT-loss.html\">Goal/WGT-loss</a></p></blockquote><p><b>lifecycleStatus</b>: active</p><p><b>priority</b>: high <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/3.1.0/CodeSystem-goal-priority.html\">Goal priority</a>#high-priority "High Priority")</span></p><p><b>description</b>: Target Systolic Blood pressure between 110 and 140 mmHg. <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"https://browser.ihtsdotools.org/\">SNOMED CT</a>#271651005 "Stable blood pressure")</span></p><p><b>subject</b>: <a href=\"Patient-cc-pat-pnoelle.html\">Patient/cc-pat-pnoelle: Patricia Noelle</a> " NOELLE"</p><p><b>start</b>: 2019-10-14</p><h3>Targets</h3><table class=\"grid\"><tr><td>-</td><td><b>Measure</b></td><td><b>Detail[x]</b></td><td><b>Due[x]</b></td></tr><tr><td>*</td><td>Systolic blood pressure <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"https://loinc.org/\">LOINC</a>#8480-6)</span></td><td>110-140 lbs</td><td>2020-04-05</td></tr></table><p><b>statusDate</b>: 2019-10-14</p><p><b>statusReason</b>: Patient knows that normal blood pressure is important for CKD, Hypertension and diabetes control.</p><p><b>expressedBy</b>: <a href=\"Patient-cc-pat-pnoelle.html\">Patient/cc-pat-pnoelle: Patricia Noelle</a> " NOELLE"</p><p><b>addresses</b>: <a href=\"Condition-ConditionCKD.html\">Condition/ConditionCKD: chronic kidney disease condition</a></p><p><b>outcomeReference</b>: <a href=\"Observation-MCCweight.html\">Observation/MCCweight: Body Weight Measured - 165 Pounds</a></p></div>"
},
"extension" : [
{
"url" : "http://hl7.org/fhir/StructureDefinition/goal-acceptance",
"extension" : [
{
"url" : "individual",
"valueReference" : {
"reference" : "Patient/cc-pat-pnoelle"
}
},
{
"url" : "status",
"valueCode" : "agree"
},
{
"url" : "priority",
"valueCodeableConcept" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/goal-priority",
"code" : "high-priority"
}
]
}
}
]
},
{
"url" : "http://hl7.org/fhir/StructureDefinition/goal-acceptance",
"extension" : [
{
"url" : "individual",
"valueReference" : {
"reference" : "Practitioner/practitionerMCC-3"
}
},
{
"url" : "status",
"valueCode" : "agree"
},
{
"url" : "priority",
"valueCodeableConcept" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/goal-priority",
"code" : "high-priority"
}
]
}
}
]
},
{
"url" : "http://hl7.org/fhir/StructureDefinition/goal-relationship",
"extension" : [
{
"url" : "type",
"valueCodeableConcept" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/goal-relationship-type",
"code" : "other"
}
],
"text" : "This goal relates to the Weight loss goal"
}
},
{
"url" : "target",
"valueReference" : {
"reference" : "Goal/WGT-loss"
}
}
]
}
],
"lifecycleStatus" : "active",
"priority" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/goal-priority",
"code" : "high-priority",
"display" : "High Priority"
}
],
"text" : "high"
},
"description" : {
"coding" : [
{
"system" : "http://snomed.info/sct",
"code" : "271651005",
"display" : "Stable blood pressure"
}
],
"text" : "Target Systolic Blood pressure between 110 and 140 mmHg."
},
"subject" : {
"reference" : "Patient/cc-pat-pnoelle",
"display" : "Patricia Noelle"
},
"startDate" : "2019-10-14",
"target" : [
{
"measure" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "8480-6",
"display" : "Systolic blood pressure"
}
]
},
"detailRange" : {
"low" : {
"value" : 110,
"unit" : "lbs",
"system" : "http://unitsofmeasure.org",
"code" : "mm[Hg]"
},
"high" : {
"value" : 140,
"unit" : "lbs",
"system" : "http://unitsofmeasure.org",
"code" : "mm[Hg]"
}
},
"dueDate" : "2020-04-05"
}
],
"statusDate" : "2019-10-14",
"statusReason" : "Patient knows that normal blood pressure is important for CKD, Hypertension and diabetes control.",
"expressedBy" : {
"reference" : "Patient/cc-pat-pnoelle",
"display" : "Patricia Noelle"
},
"addresses" : [
{
"reference" : "Condition/ConditionCKD",
"display" : "chronic kidney disease condition"
}
],
"outcomeReference" : [
{
"reference" : "Observation/MCCweight",
"display" : "Body Weight Measured - 165 Pounds"
}
]
}
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