The ADI goal represents the patient’s advance healthcare decision goals for the medical interventions that will be part of the clinician-authored care plan that will drive treatment. The patient’s documented goals of the medical care they will receive is based on the context or condition specified, and is intended to guide the provider-authored interventions that will be documented by the care team providing the treatment interventions that meet those documented patient goals. This allows a person-centered approach to care planning that reflects the specific goals, preferences, and priorities of that person which can then be merged with the clinical care plan so as to enable a jointly developed plan of care between the provider and person receiving care.

• Text Summary
• Differential Table
• Snapshot Table
• Snapshot Table (Must Support)
• All

This structure is derived from USCoreGoalProfile

Name	Flags	Card.	Type	Description & Constraints
Goal	I	0..*	USCoreGoalProfile	This is an abstract profile Describes the intended objective(s) for a patient, group or organization goal-subject-expressedby: subject and expressedBy refer to the same patient
text	S	1..1	Narrative	Text summary of the resource, for human interpretation
category	S	0..*	CodeableConcept	E.g. Treatment, dietary, behavioral, etc.
text	S	0..1	string	Plain text representation of the concept
description
padi-contextualValue-extension		0..1	(Complex)	Contextual Value URL: http://hl7.org/fhir/us/pacio-adi/StructureDefinition/padi-contextualValue-extension
target
measure	S	0..1	CodeableConcept	The parameter whose value is being tracked
detail[x]	S	0..1	Quantity, Range, CodeableConcept, string, boolean, integer, Ratio	The target value to be achieved
expressedBy	S	1..1	Reference(US Core Patient Profile)	Who's responsible for creating Goal?
note	S	0..*	Annotation	Comments about the goal
Documentation for this format

Name	Flags	Card.	Type	Description & Constraints
Goal	I	0..*	USCoreGoalProfile	This is an abstract profile Describes the intended objective(s) for a patient, group or organization goal-subject-expressedby: subject and expressedBy refer to the same patient
id	Σ	0..1	string	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) Max Binding: AllLanguages: A human language.
text	S	1..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	SΣ	0..*	CodeableConcept	E.g. Treatment, dietary, behavioral, etc. Binding: GoalCategory (example): Codes for grouping and sorting goals.
id		0..1	string	Unique id for inter-element referencing
Slices for extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
coding	Σ	0..*	Coding	Code defined by a terminology system
text	SΣ	0..1	string	Plain text representation of the concept
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: SNOMEDCTClinicalFindings (example): Codes providing the details of a particular goal. This will generally be system or implementation guide-specific. In many systems, only the text element will be used.
id		0..1	string	Unique id for inter-element referencing
Slices for extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
padi-contextualValue-extension		0..1	(Complex)	Contextual Value URL: http://hl7.org/fhir/us/pacio-adi/StructureDefinition/padi-contextualValue-extension
coding	Σ	0..*	Coding	Code defined by a terminology system
text	Σ	0..1	string	Plain text representation of the concept
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	SI	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	SΣI	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]	SΣI	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	SΣ	1..1	Reference(US Core Patient Profile)	Who's responsible for creating Goal?
addresses		0..*	Reference(Condition | Observation | MedicationStatement | NutritionOrder | ServiceRequest | RiskAssessment)	Issues addressed by this goal
note	S	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

Name	Flags	Card.	Type	Description & Constraints
Goal	I	0..*	USCoreGoalProfile	This is an abstract profile Describes the intended objective(s) for a patient, group or organization goal-subject-expressedby: subject and expressedBy refer to the same patient
text		1..1	Narrative	Text summary of the resource, for human interpretation
lifecycleStatus	?!Σ	1..1	code	proposed | planned | accepted | active | on-hold | completed | cancelled | entered-in-error | rejected Binding: GoalLifecycleStatus (required)
category	Σ	0..*	CodeableConcept	E.g. Treatment, dietary, behavioral, etc. Binding: GoalCategory (example): Codes for grouping and sorting goals.
text	Σ	0..1	string	Plain text representation of the concept
description	Σ	1..1	CodeableConcept	Code or text describing goal Binding: SNOMEDCTClinicalFindings (example): Codes providing the details of a particular goal. This will generally be system or implementation guide-specific. In many systems, only the text element will be used.
subject	Σ	1..1	Reference(US Core Patient Profile)	Who this goal is intended for
target	I	0..*	BackboneElement	Target outcome for the goal
measure	ΣI	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]	ΣI	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]	Σ	0..1		Reach goal on or before
dueDate			date
expressedBy	Σ	1..1	Reference(US Core Patient Profile)	Who's responsible for creating Goal?
note		0..*	Annotation	Comments about the goal
Documentation for this format

This structure is derived from USCoreGoalProfile

Summary

Mandatory: 2 elements
Must-Support: 7 elements

Structures

This structure refers to these other structures:

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

Extensions

This structure refers to these extensions:

• http://hl7.org/fhir/us/pacio-adi/StructureDefinition/padi-contextualValue-extension

Differential View

This structure is derived from USCoreGoalProfile

Name	Flags	Card.	Type	Description & Constraints
Goal	I	0..*	USCoreGoalProfile	This is an abstract profile Describes the intended objective(s) for a patient, group or organization goal-subject-expressedby: subject and expressedBy refer to the same patient
text	S	1..1	Narrative	Text summary of the resource, for human interpretation
category	S	0..*	CodeableConcept	E.g. Treatment, dietary, behavioral, etc.
text	S	0..1	string	Plain text representation of the concept
description
padi-contextualValue-extension		0..1	(Complex)	Contextual Value URL: http://hl7.org/fhir/us/pacio-adi/StructureDefinition/padi-contextualValue-extension
target
measure	S	0..1	CodeableConcept	The parameter whose value is being tracked
detail[x]	S	0..1	Quantity, Range, CodeableConcept, string, boolean, integer, Ratio	The target value to be achieved
expressedBy	S	1..1	Reference(US Core Patient Profile)	Who's responsible for creating Goal?
note	S	0..*	Annotation	Comments about the goal
Documentation for this format

Snapshot View

Name	Flags	Card.	Type	Description & Constraints
Goal	I	0..*	USCoreGoalProfile	This is an abstract profile Describes the intended objective(s) for a patient, group or organization goal-subject-expressedby: subject and expressedBy refer to the same patient
id	Σ	0..1	string	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) Max Binding: AllLanguages: A human language.
text	S	1..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	SΣ	0..*	CodeableConcept	E.g. Treatment, dietary, behavioral, etc. Binding: GoalCategory (example): Codes for grouping and sorting goals.
id		0..1	string	Unique id for inter-element referencing
Slices for extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
coding	Σ	0..*	Coding	Code defined by a terminology system
text	SΣ	0..1	string	Plain text representation of the concept
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: SNOMEDCTClinicalFindings (example): Codes providing the details of a particular goal. This will generally be system or implementation guide-specific. In many systems, only the text element will be used.
id		0..1	string	Unique id for inter-element referencing
Slices for extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
padi-contextualValue-extension		0..1	(Complex)	Contextual Value URL: http://hl7.org/fhir/us/pacio-adi/StructureDefinition/padi-contextualValue-extension
coding	Σ	0..*	Coding	Code defined by a terminology system
text	Σ	0..1	string	Plain text representation of the concept
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	SI	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	SΣI	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]	SΣI	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	SΣ	1..1	Reference(US Core Patient Profile)	Who's responsible for creating Goal?
addresses		0..*	Reference(Condition | Observation | MedicationStatement | NutritionOrder | ServiceRequest | RiskAssessment)	Issues addressed by this goal
note	S	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