Patient-Reported Outcome Measures (PROM) and Goal Attainment Scaling (GAS) are two alternative approaches for measuring goal outcomes, progress and achievement. A person-centered goal may use either of these approaches where the choice is based on practitioner or patient preferences, support by a provider's system, or availability of an appropriate PROM instrument. This profile supports goals using PROM measurement. One example PROM is the seven-question Generalized Anxiety Disorder (GAS-7) tool that assesses the presence and degree of a patient's anxiety.

Mandatory and Must Support Data Elements

This Person-Centered PROM Goal Profile inherits shared definitions from the PCO Goal Profile; refer to it for scope and usage guidance. It sets minimum expectations for all person-centered Goal resources. Only added constraints are listed here.

Each Goal must have:

1. a status
2. text description of the goal
3. a patient
4. a start date
5. target measure LOINC code for a PROM score
6. target detail quantity with a comparator and value, e.g. < 10

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)

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

Name	Flags	Card.	Type	Description & Constraints
Goal		0..*	PCOGoalProfile	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:$this Binding: GoalCategory (example): Codes for grouping and sorting goals. ele-1: All FHIR elements must have a @value or children
category:pco	SΣ	0..1	CodeableConcept	Person-Centered resource category Binding: Person-Centered Categories (required) ele-1: All FHIR elements must have a @value or children
category:goal-domain	SΣ	0..*	CodeableConcept	Person-Centered Outcome goal domain category Binding: PCO Goal Domain Categories (required): Note that other codes are permitted, see Required Bindings When Slicing by Value Sets ele-1: All FHIR elements must have a @value or children
description	SΣ	1..1	CodeableConcept	(USCDI) Code or text describing goal Binding: US Core Goal Codes (extensible): Value set to describe the Goal ele-1: All FHIR elements must have a @value or children
subject	SΣ	1..1	Reference(US Core Patient Profile)	(USCDI) Who this goal is intended for ele-1: All FHIR elements must have a @value or children
start[x]	SΣ	1..1	date	(USCDI) When goal pursuit begins ele-1: All FHIR elements must have a @value or children
target	SC	1..1	BackboneElement	(USCDI) Target outcome for the goal ele-1: All FHIR elements must have a @value or children gol-1: Goal.target.measure is required if Goal.target.detail is populated
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
measure	SΣC	1..1	CodeableConcept	Target score for evaluating PCO Goal using PROMs Binding: PROM Target Measure Scores (extensible) ele-1: All FHIR elements must have a @value or children
Slices for detail[x]	ΣC	1..1	Quantity	The target value to be achieved Slice: Unordered, Closed by type:$this Binding Description (No ValueSet): (example): Codes to identify the target value of the focus to be achieved to signify the fulfillment of the goal. ele-1: All FHIR elements must have a @value or children
detail[x]:detailQuantity	SΣC	1..1	Quantity	Target value for the PROM score Binding Description (No ValueSet): (example): Codes to identify the target value of the focus to be achieved to signify the fulfillment of the goal. ele-1: All FHIR elements must have a @value or children
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
Goal.target.measure	extensible	PROMTargetMeasures http://hl7.org/fhir/us/pco/ValueSet/prom-target-measures from this IG
Goal.target.detail[x]	example
Goal.target.detail[x]:detailQuantity	example

This structure is derived from PCOGoalProfile

Name	Flags	Card.	Type	Description & Constraints
Goal		0..*	PCOGoalProfile	Describes the intended objective(s) for a patient, group or organization
target		1..1	BackboneElement	(USCDI) Target outcome for the goal
measure	S	1..1	CodeableConcept	Target score for evaluating PCO Goal using PROMs Binding: PROM Target Measure Scores (extensible)
Slices for detail[x]		1..1	Quantity	The target value to be achieved Slice: Unordered, Open by type:$this
detail[x]:detailQuantity	S	1..1	Quantity	Target value for the PROM score
Documentation for this format

Terminology Bindings (Differential)

Path	Conformance	ValueSet	URI
Goal.target.measure	extensible	PROMTargetMeasures http://hl7.org/fhir/us/pco/ValueSet/prom-target-measures from this IG

Name	Flags	Card.	Type	Description & Constraints
Goal		0..*	PCOGoalProfile	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:$this Binding: GoalCategory (example): Codes for grouping and sorting goals.
category:pco	SΣ	0..1	CodeableConcept	Person-Centered resource category Binding: Person-Centered Categories (required)
category:goal-domain	SΣ	0..*	CodeableConcept	Person-Centered Outcome goal domain category Binding: PCO Goal Domain Categories (required): Note that other codes are permitted, see Required Bindings When Slicing by Value Sets
priority	Σ	0..1	CodeableConcept	high-priority | medium-priority | low-priority Binding: GoalPriority (preferred): The level of importance associated with a goal.
description	SΣ	1..1	CodeableConcept	(USCDI) Code or text describing goal Binding: US Core Goal Codes (extensible): Value set to describe the Goal
subject	SΣ	1..1	Reference(US Core Patient Profile)	(USCDI) Who this goal is intended for
start[x]	SΣ	1..1	date S	(USCDI) When goal pursuit begins
target	SC	1..1	BackboneElement	(USCDI) Target outcome for the goal gol-1: Goal.target.measure is required if Goal.target.detail is populated
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
measure	SΣC	1..1	CodeableConcept	Target score for evaluating PCO Goal using PROMs Binding: PROM Target Measure Scores (extensible)
Slices for detail[x]	ΣC	1..1	Quantity	The target value to be achieved Slice: Unordered, Closed by type:$this Binding Description (No ValueSet): (example): Codes to identify the target value of the focus to be achieved to signify the fulfillment of the goal.
detail[x]:detailQuantity	SΣC	1..1	Quantity	Target value for the PROM score Binding Description (No ValueSet): (example): Codes to identify the target value of the focus to be achieved to signify the fulfillment of the goal.
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	extensible	PROMTargetMeasures http://hl7.org/fhir/us/pco/ValueSet/prom-target-measures from this IG
Goal.target.detail[x]	example
Goal.target.detail[x]:detailQuantity	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..*	PCOGoalProfile	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:$this Binding: GoalCategory (example): Codes for grouping and sorting goals. ele-1: All FHIR elements must have a @value or children
category:pco	SΣ	0..1	CodeableConcept	Person-Centered resource category Binding: Person-Centered Categories (required) ele-1: All FHIR elements must have a @value or children
category:goal-domain	SΣ	0..*	CodeableConcept	Person-Centered Outcome goal domain category Binding: PCO Goal Domain Categories (required): Note that other codes are permitted, see Required Bindings When Slicing by Value Sets ele-1: All FHIR elements must have a @value or children
description	SΣ	1..1	CodeableConcept	(USCDI) Code or text describing goal Binding: US Core Goal Codes (extensible): Value set to describe the Goal ele-1: All FHIR elements must have a @value or children
subject	SΣ	1..1	Reference(US Core Patient Profile)	(USCDI) Who this goal is intended for ele-1: All FHIR elements must have a @value or children
start[x]	SΣ	1..1	date	(USCDI) When goal pursuit begins ele-1: All FHIR elements must have a @value or children
target	SC	1..1	BackboneElement	(USCDI) Target outcome for the goal ele-1: All FHIR elements must have a @value or children gol-1: Goal.target.measure is required if Goal.target.detail is populated
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
measure	SΣC	1..1	CodeableConcept	Target score for evaluating PCO Goal using PROMs Binding: PROM Target Measure Scores (extensible) ele-1: All FHIR elements must have a @value or children
Slices for detail[x]	ΣC	1..1	Quantity	The target value to be achieved Slice: Unordered, Closed by type:$this Binding Description (No ValueSet): (example): Codes to identify the target value of the focus to be achieved to signify the fulfillment of the goal. ele-1: All FHIR elements must have a @value or children
detail[x]:detailQuantity	SΣC	1..1	Quantity	Target value for the PROM score Binding Description (No ValueSet): (example): Codes to identify the target value of the focus to be achieved to signify the fulfillment of the goal. ele-1: All FHIR elements must have a @value or children
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
Goal.target.measure	extensible	PROMTargetMeasures http://hl7.org/fhir/us/pco/ValueSet/prom-target-measures from this IG
Goal.target.detail[x]	example
Goal.target.detail[x]:detailQuantity	example

Differential View

This structure is derived from PCOGoalProfile

Name	Flags	Card.	Type	Description & Constraints
Goal		0..*	PCOGoalProfile	Describes the intended objective(s) for a patient, group or organization
target		1..1	BackboneElement	(USCDI) Target outcome for the goal
measure	S	1..1	CodeableConcept	Target score for evaluating PCO Goal using PROMs Binding: PROM Target Measure Scores (extensible)
Slices for detail[x]		1..1	Quantity	The target value to be achieved Slice: Unordered, Open by type:$this
detail[x]:detailQuantity	S	1..1	Quantity	Target value for the PROM score
Documentation for this format

Terminology Bindings (Differential)

Path	Conformance	ValueSet	URI
Goal.target.measure	extensible	PROMTargetMeasures http://hl7.org/fhir/us/pco/ValueSet/prom-target-measures from this IG

Snapshot View

Name	Flags	Card.	Type	Description & Constraints
Goal		0..*	PCOGoalProfile	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:$this Binding: GoalCategory (example): Codes for grouping and sorting goals.
category:pco	SΣ	0..1	CodeableConcept	Person-Centered resource category Binding: Person-Centered Categories (required)
category:goal-domain	SΣ	0..*	CodeableConcept	Person-Centered Outcome goal domain category Binding: PCO Goal Domain Categories (required): Note that other codes are permitted, see Required Bindings When Slicing by Value Sets
priority	Σ	0..1	CodeableConcept	high-priority | medium-priority | low-priority Binding: GoalPriority (preferred): The level of importance associated with a goal.
description	SΣ	1..1	CodeableConcept	(USCDI) Code or text describing goal Binding: US Core Goal Codes (extensible): Value set to describe the Goal
subject	SΣ	1..1	Reference(US Core Patient Profile)	(USCDI) Who this goal is intended for
start[x]	SΣ	1..1	date S	(USCDI) When goal pursuit begins
target	SC	1..1	BackboneElement	(USCDI) Target outcome for the goal gol-1: Goal.target.measure is required if Goal.target.detail is populated
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
measure	SΣC	1..1	CodeableConcept	Target score for evaluating PCO Goal using PROMs Binding: PROM Target Measure Scores (extensible)
Slices for detail[x]	ΣC	1..1	Quantity	The target value to be achieved Slice: Unordered, Closed by type:$this Binding Description (No ValueSet): (example): Codes to identify the target value of the focus to be achieved to signify the fulfillment of the goal.
detail[x]:detailQuantity	SΣC	1..1	Quantity	Target value for the PROM score Binding Description (No ValueSet): (example): Codes to identify the target value of the focus to be achieved to signify the fulfillment of the goal.
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	extensible	PROMTargetMeasures http://hl7.org/fhir/us/pco/ValueSet/prom-target-measures from this IG
Goal.target.detail[x]	example
Goal.target.detail[x]:detailQuantity	example
Goal.outcomeCode	example	SNOMEDCTClinicalFindings http://hl7.org/fhir/ValueSet/clinical-findings from the FHIR Standard

This structure is derived from PCOGoalProfile

Summary

Mandatory: 4 elements
Must-Support: 2 elements

Slices

This structure defines the following Slices:

• The element 1 is sliced based on the value of Goal.target.detail[x]

Maturity: 2