The PCO Goal Profile inherits from the US Core Goal Profile; refer to it for scope and usage guidance. It sets minimum expectations for the Goal resource to record, search, and fetch Goal information associated with a patient to promote interoperability and adoption through common implementation.

Example Usage Scenarios:

The following are example usage scenarios for this Profile:

• Record or update a person's goals.
• Query for a patient's person-centered goals.
• Query for a patient's goals in a specified goal domain category.
• Query for a patient's goals that address a specified assessment observation.

Mandatory and Must Support Data Elements

The following data elements must always be present or must be supported if the data is present in the sending system (Must Support definition). They are presented below with a simple human-readable explanation. Profile specific guidance and examples are provided as well. The Formal Profile Definition 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
4. a start date

Each Goal must support:

1. additional categories that further specify the goal*
2. target date(s)
3. who established the goal
4. addresses What Matters Assessment observation(s)

Profile Specific Implementation Guidance:

• *Although Goal 'pco' and 'goal-domain' categories are both marked as Must Support, the server system is not required to support both, but SHALL support at least one of these elements. A client application SHALL support both elements. These categories enable quality measures and other applications to determine which patient goals are person-centered.

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

Name	Flags	Card.	Type	Description & Constraints
Goal		0..*	USCoreGoalProfile	Describes the intended objective(s) for a patient, group or organization dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources dom-3: If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource dom-4: If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated dom-5: If a resource is contained in another resource, it SHALL NOT have a security label dom-6: A resource should have narrative for robust management
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created ele-1: All FHIR elements must have a @value or children
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
lifecycleStatus	?!SΣ	1..1	code	(USCDI) proposed | planned | accepted | active | on-hold | completed | cancelled | entered-in-error | rejected Binding: GoalLifecycleStatus (required) ele-1: All FHIR elements must have a @value or children
Slices for category	SΣ	0..*	CodeableConcept	E.g. Treatment, dietary, behavioral, etc. Slice: Unordered, Open by value:$this Binding: GoalCategory (example): Codes for grouping and sorting goals. ele-1: All FHIR elements must have a @value or children
category:pco	SΣ	0..1	CodeableConcept	Person-Centered resource category Binding: Person-Centered Categories (required) ele-1: All FHIR elements must have a @value or children
category:goal-domain	SΣ	0..*	CodeableConcept	Person-Centered Outcome goal domain category Binding: PCO Goal Domain Categories (required): Note that other codes are permitted, see Required Bindings When Slicing by Value Sets ele-1: All FHIR elements must have a @value or children
description	SΣ	1..1	CodeableConcept	(USCDI) Code or text describing goal Binding: US Core Goal Codes (extensible): Value set to describe the Goal ele-1: All FHIR elements must have a @value or children
subject	SΣ	1..1	Reference(US Core Patient Profile)	(USCDI) Who this goal is intended for ele-1: All FHIR elements must have a @value or children
start[x]	SΣ	1..1	date	(USCDI) When goal pursuit begins ele-1: All FHIR elements must have a @value or children
target	SC	0..*	BackboneElement	(USCDI) Target outcome for the goal ele-1: All FHIR elements must have a @value or children gol-1: Goal.target.measure is required if Goal.target.detail is populated
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
due[x]	SΣ	0..1		(USCDI) Reach goal on or before ele-1: All FHIR elements must have a @value or children
dueDate			date
expressedBy	SΣ	0..1	Reference(US Core Patient Profile | US Core Practitioner Profile | US Core RelatedPerson Profile)	Who's responsible for creating Goal? ele-1: All FHIR elements must have a @value or children
Slices for addresses		0..*	Reference(Condition | Observation | RiskAssessment)	Issues addressed by this goal Slice: Unordered, Open by profile:resolve() ele-1: All FHIR elements must have a @value or children
addresses:SupportedAddresses	S	0..*	Reference(What Matters Assessment)	What Matters Assessment or Priority ele-1: All FHIR elements must have a @value or children
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet	URI
Goal.lifecycleStatus	required	GoalLifecycleStatus http://hl7.org/fhir/ValueSet/goal-status from the FHIR Standard
Goal.category	example	GoalCategory http://hl7.org/fhir/ValueSet/goal-category from the FHIR Standard
Goal.category:pco	required	PCOCategories http://hl7.org/fhir/us/pco/ValueSet/pco-categories from this IG
Goal.category:goal-domain	required	PCOGoalDomainCategories http://hl7.org/fhir/us/pco/ValueSet/pco-goal-domain-categories from this IG
Goal.description	extensible	USCoreGoalCodes http://hl7.org/fhir/us/core/ValueSet/us-core-goal-description

This structure is derived from USCoreGoalProfile

Name	Flags	Card.	Type	Description & Constraints
Goal			USCoreGoalProfile
Slices for category	S	0..*	CodeableConcept	E.g. Treatment, dietary, behavioral, etc. Slice: Unordered, Open by value:$this
category:pco	S	0..1	CodeableConcept	Person-Centered resource category Binding: Person-Centered Categories (required)
category:goal-domain	S	0..*	CodeableConcept	Person-Centered Outcome goal domain category Binding: PCO Goal Domain Categories (required): Note that other codes are permitted, see Required Bindings When Slicing by Value Sets
start[x]		1..1	date	(USCDI) When goal pursuit begins
expressedBy	S	0..1	Reference(US Core Patient Profile | US Core Practitioner Profile | US Core RelatedPerson Profile)	Who's responsible for creating Goal?
Slices for addresses		0..*	Reference(Condition | Observation | RiskAssessment)	Issues addressed by this goal Slice: Unordered, Open by profile:resolve()
addresses:SupportedAddresses	S	0..*	Reference(What Matters Assessment)	What Matters Assessment or Priority
Documentation for this format

Terminology Bindings (Differential)

Path	Conformance	ValueSet	URI
Goal.category:pco	required	PCOCategories http://hl7.org/fhir/us/pco/ValueSet/pco-categories from this IG
Goal.category:goal-domain	required	PCOGoalDomainCategories http://hl7.org/fhir/us/pco/ValueSet/pco-goal-domain-categories from this IG

Name	Flags	Card.	Type	Description & Constraints
Goal		0..*	USCoreGoalProfile	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	(USCDI) 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.
Slices for category	SΣ	0..*	CodeableConcept	E.g. Treatment, dietary, behavioral, etc. Slice: Unordered, Open by value:$this Binding: GoalCategory (example): Codes for grouping and sorting goals.
category:pco	SΣ	0..1	CodeableConcept	Person-Centered resource category Binding: Person-Centered Categories (required)
category:goal-domain	SΣ	0..*	CodeableConcept	Person-Centered Outcome goal domain category Binding: PCO Goal Domain Categories (required): Note that other codes are permitted, see Required Bindings When Slicing by Value Sets
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	(USCDI) 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)	(USCDI) Who this goal is intended for
start[x]	SΣ	1..1	date S	(USCDI) When goal pursuit begins
target	SC	0..*	BackboneElement	(USCDI) Target outcome for the goal gol-1: Goal.target.measure is required if Goal.target.detail is populated
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 Description (No ValueSet): (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		(USCDI) 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	0..1	Reference(US Core Patient Profile | US Core Practitioner Profile | US Core RelatedPerson Profile)	Who's responsible for creating Goal?
Slices for addresses		0..*	Reference(Condition | Observation | RiskAssessment)	Issues addressed by this goal Slice: Unordered, Open by profile:resolve()
addresses:SupportedAddresses	S	0..*	Reference(What Matters Assessment)	What Matters Assessment or Priority
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	URI
Goal.language	preferred	CommonLanguages http://hl7.org/fhir/ValueSet/languages from the FHIR Standard Additional Bindings Purpose AllLanguages Max Binding
Goal.lifecycleStatus	required	GoalLifecycleStatus http://hl7.org/fhir/ValueSet/goal-status from the FHIR Standard
Goal.achievementStatus	preferred	GoalAchievementStatus http://hl7.org/fhir/ValueSet/goal-achievement from the FHIR Standard
Goal.category	example	GoalCategory http://hl7.org/fhir/ValueSet/goal-category from the FHIR Standard
Goal.category:pco	required	PCOCategories http://hl7.org/fhir/us/pco/ValueSet/pco-categories from this IG
Goal.category:goal-domain	required	PCOGoalDomainCategories http://hl7.org/fhir/us/pco/ValueSet/pco-goal-domain-categories from this IG
Goal.priority	preferred	GoalPriority http://hl7.org/fhir/ValueSet/goal-priority from the FHIR Standard
Goal.description	extensible	USCoreGoalCodes http://hl7.org/fhir/us/core/ValueSet/us-core-goal-description
Goal.target.measure	example	LOINCCodes (a valid code from LOINC) http://hl7.org/fhir/ValueSet/observation-codes from the FHIR Standard
Goal.target.detail[x]	example
Goal.outcomeCode	example	SNOMEDCTClinicalFindings http://hl7.org/fhir/ValueSet/clinical-findings from the FHIR Standard

Key Elements View

Name	Flags	Card.	Type	Description & Constraints
Goal		0..*	USCoreGoalProfile	Describes the intended objective(s) for a patient, group or organization dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources dom-3: If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource dom-4: If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated dom-5: If a resource is contained in another resource, it SHALL NOT have a security label dom-6: A resource should have narrative for robust management
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created ele-1: All FHIR elements must have a @value or children
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
lifecycleStatus	?!SΣ	1..1	code	(USCDI) proposed | planned | accepted | active | on-hold | completed | cancelled | entered-in-error | rejected Binding: GoalLifecycleStatus (required) ele-1: All FHIR elements must have a @value or children
Slices for category	SΣ	0..*	CodeableConcept	E.g. Treatment, dietary, behavioral, etc. Slice: Unordered, Open by value:$this Binding: GoalCategory (example): Codes for grouping and sorting goals. ele-1: All FHIR elements must have a @value or children
category:pco	SΣ	0..1	CodeableConcept	Person-Centered resource category Binding: Person-Centered Categories (required) ele-1: All FHIR elements must have a @value or children
category:goal-domain	SΣ	0..*	CodeableConcept	Person-Centered Outcome goal domain category Binding: PCO Goal Domain Categories (required): Note that other codes are permitted, see Required Bindings When Slicing by Value Sets ele-1: All FHIR elements must have a @value or children
description	SΣ	1..1	CodeableConcept	(USCDI) Code or text describing goal Binding: US Core Goal Codes (extensible): Value set to describe the Goal ele-1: All FHIR elements must have a @value or children
subject	SΣ	1..1	Reference(US Core Patient Profile)	(USCDI) Who this goal is intended for ele-1: All FHIR elements must have a @value or children
start[x]	SΣ	1..1	date	(USCDI) When goal pursuit begins ele-1: All FHIR elements must have a @value or children
target	SC	0..*	BackboneElement	(USCDI) Target outcome for the goal ele-1: All FHIR elements must have a @value or children gol-1: Goal.target.measure is required if Goal.target.detail is populated
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
due[x]	SΣ	0..1		(USCDI) Reach goal on or before ele-1: All FHIR elements must have a @value or children
dueDate			date
expressedBy	SΣ	0..1	Reference(US Core Patient Profile | US Core Practitioner Profile | US Core RelatedPerson Profile)	Who's responsible for creating Goal? ele-1: All FHIR elements must have a @value or children
Slices for addresses		0..*	Reference(Condition | Observation | RiskAssessment)	Issues addressed by this goal Slice: Unordered, Open by profile:resolve() ele-1: All FHIR elements must have a @value or children
addresses:SupportedAddresses	S	0..*	Reference(What Matters Assessment)	What Matters Assessment or Priority ele-1: All FHIR elements must have a @value or children
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet	URI
Goal.lifecycleStatus	required	GoalLifecycleStatus http://hl7.org/fhir/ValueSet/goal-status from the FHIR Standard
Goal.category	example	GoalCategory http://hl7.org/fhir/ValueSet/goal-category from the FHIR Standard
Goal.category:pco	required	PCOCategories http://hl7.org/fhir/us/pco/ValueSet/pco-categories from this IG
Goal.category:goal-domain	required	PCOGoalDomainCategories http://hl7.org/fhir/us/pco/ValueSet/pco-goal-domain-categories from this IG
Goal.description	extensible	USCoreGoalCodes http://hl7.org/fhir/us/core/ValueSet/us-core-goal-description

Differential View

This structure is derived from USCoreGoalProfile

Name	Flags	Card.	Type	Description & Constraints
Goal			USCoreGoalProfile
Slices for category	S	0..*	CodeableConcept	E.g. Treatment, dietary, behavioral, etc. Slice: Unordered, Open by value:$this
category:pco	S	0..1	CodeableConcept	Person-Centered resource category Binding: Person-Centered Categories (required)
category:goal-domain	S	0..*	CodeableConcept	Person-Centered Outcome goal domain category Binding: PCO Goal Domain Categories (required): Note that other codes are permitted, see Required Bindings When Slicing by Value Sets
start[x]		1..1	date	(USCDI) When goal pursuit begins
expressedBy	S	0..1	Reference(US Core Patient Profile | US Core Practitioner Profile | US Core RelatedPerson Profile)	Who's responsible for creating Goal?
Slices for addresses		0..*	Reference(Condition | Observation | RiskAssessment)	Issues addressed by this goal Slice: Unordered, Open by profile:resolve()
addresses:SupportedAddresses	S	0..*	Reference(What Matters Assessment)	What Matters Assessment or Priority
Documentation for this format

Terminology Bindings (Differential)

Path	Conformance	ValueSet	URI
Goal.category:pco	required	PCOCategories http://hl7.org/fhir/us/pco/ValueSet/pco-categories from this IG
Goal.category:goal-domain	required	PCOGoalDomainCategories http://hl7.org/fhir/us/pco/ValueSet/pco-goal-domain-categories from this IG

Snapshot View

Name	Flags	Card.	Type	Description & Constraints
Goal		0..*	USCoreGoalProfile	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	(USCDI) 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.
Slices for category	SΣ	0..*	CodeableConcept	E.g. Treatment, dietary, behavioral, etc. Slice: Unordered, Open by value:$this Binding: GoalCategory (example): Codes for grouping and sorting goals.
category:pco	SΣ	0..1	CodeableConcept	Person-Centered resource category Binding: Person-Centered Categories (required)
category:goal-domain	SΣ	0..*	CodeableConcept	Person-Centered Outcome goal domain category Binding: PCO Goal Domain Categories (required): Note that other codes are permitted, see Required Bindings When Slicing by Value Sets
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	(USCDI) 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)	(USCDI) Who this goal is intended for
start[x]	SΣ	1..1	date S	(USCDI) When goal pursuit begins
target	SC	0..*	BackboneElement	(USCDI) Target outcome for the goal gol-1: Goal.target.measure is required if Goal.target.detail is populated
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 Description (No ValueSet): (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		(USCDI) 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	0..1	Reference(US Core Patient Profile | US Core Practitioner Profile | US Core RelatedPerson Profile)	Who's responsible for creating Goal?
Slices for addresses		0..*	Reference(Condition | Observation | RiskAssessment)	Issues addressed by this goal Slice: Unordered, Open by profile:resolve()
addresses:SupportedAddresses	S	0..*	Reference(What Matters Assessment)	What Matters Assessment or Priority
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	URI
Goal.language	preferred	CommonLanguages http://hl7.org/fhir/ValueSet/languages from the FHIR Standard Additional Bindings Purpose AllLanguages Max Binding
Goal.lifecycleStatus	required	GoalLifecycleStatus http://hl7.org/fhir/ValueSet/goal-status from the FHIR Standard
Goal.achievementStatus	preferred	GoalAchievementStatus http://hl7.org/fhir/ValueSet/goal-achievement from the FHIR Standard
Goal.category	example	GoalCategory http://hl7.org/fhir/ValueSet/goal-category from the FHIR Standard
Goal.category:pco	required	PCOCategories http://hl7.org/fhir/us/pco/ValueSet/pco-categories from this IG
Goal.category:goal-domain	required	PCOGoalDomainCategories http://hl7.org/fhir/us/pco/ValueSet/pco-goal-domain-categories from this IG
Goal.priority	preferred	GoalPriority http://hl7.org/fhir/ValueSet/goal-priority from the FHIR Standard
Goal.description	extensible	USCoreGoalCodes http://hl7.org/fhir/us/core/ValueSet/us-core-goal-description
Goal.target.measure	example	LOINCCodes (a valid code from LOINC) http://hl7.org/fhir/ValueSet/observation-codes from the FHIR Standard
Goal.target.detail[x]	example
Goal.outcomeCode	example	SNOMEDCTClinicalFindings http://hl7.org/fhir/ValueSet/clinical-findings from the FHIR Standard

This structure is derived from USCoreGoalProfile

Summary

Mandatory: 1 element
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)
• US Core Practitioner Profile (http://hl7.org/fhir/us/core/StructureDefinition/us-core-practitioner)
• US Core RelatedPerson Profile (http://hl7.org/fhir/us/core/StructureDefinition/us-core-relatedperson)
• What Matters Assessment (http://hl7.org/fhir/us/pco/StructureDefinition/pco-what-matters-assessment)

Slices

This structure defines the following Slices:

• The element 1 is sliced based on the value of Goal.category
• The element 1 is sliced based on the value of Goal.addresses

Maturity: 2