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. description of the goal*
3. a patient

Each Goal Must Support:

1. start date*
2. target date(s)*
3. who established the goal*

*see guidance below

Profile Specific Implementation Guidance:

• *Although both Goal.startDate and Goal.target.dueDate are marked as Must Support, the Server system is not required to support both, but SHALL support at least one of these elements. The Client application SHALL support both elements.
• *Goals are often captured as text and communicated in Goal.description.text. When the goal is a Social Determinants of Health (SDOH) goal, use the preferred Social Determinants of Health Goals binding.
• See the Screening and Assessments guidance page for more information when exchanging Social Determinants of Health (SDOH) Goals

• *The profile elements Goal.expressedBy communicate the individual level provenance author data corresponding to the U.S. Core Data for Interoperability (USCDI) Provenance Author Data Elements.

Changes since version 7.0.0:

• 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 (preferred): Value set to describe the Goal Additional Bindings Purpose Social Determinants of Health Goals Preferred
subject	S	1..1	Reference(US Core Patient Profile S | Group | Organization)	Who this goal is intended for
start[x]	S	0..1		When goal pursuit begins
startDate			date S
startCodeableConcept			CodeableConcept
target	S	0..*	BackboneElement	Target outcome for the goal
due[x]	S	0..1		Reach goal on or before
dueDate			date S
dueDuration			Duration
expressedBy	S	0..1	Reference(US Core Practitioner Profile S | US Core Patient Profile | PractitionerRole | US Core RelatedPerson Profile)	Who's responsible for creating Goal?
Documentation for this format

Terminology Bindings (Differential)

Path	Conformance	ValueSet	URI
Goal.lifecycleStatus	required	GoalLifecycleStatus http://hl7.org/fhir/ValueSet/goal-status from the FHIR Standard
Goal.description	preferred	USCoreGoalCodes http://hl7.org/fhir/us/core/ValueSet/us-core-goal-description from this IG

Name	Flags	Card.	Type	Description & Constraints
Goal		0..*	Goal	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	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
description	SΣ	1..1	CodeableConcept	Code or text describing goal Binding: US Core Goal Codes (preferred): Value set to describe the Goal Additional Bindings Purpose Social Determinants of Health Goals Preferred ele-1: All FHIR elements must have a @value or children
subject	SΣ	1..1	Reference(US Core Patient Profile)	Who this goal is intended for ele-1: All FHIR elements must have a @value or children
start[x]	SΣ	0..1		When goal pursuit begins Binding: GoalStartEvent (example): Codes describing events that can trigger the initiation of a goal. ele-1: All FHIR elements must have a @value or children
startDate			date
target	SC	0..*	BackboneElement	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		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 Practitioner Profile)	Who's responsible for creating Goal? 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.description	preferred	USCoreGoalCodes http://hl7.org/fhir/us/core/ValueSet/us-core-goal-description from this IG
Goal.start[x]	example	GoalStartEvent http://hl7.org/fhir/ValueSet/goal-start-event from the FHIR Standard

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 (preferred): Value set to describe the Goal Additional Bindings Purpose Social Determinants of Health Goals Preferred
subject	SΣ	1..1	Reference(US Core Patient Profile S | Group | Organization)	Who this goal is intended for
start[x]	SΣ	0..1		When goal pursuit begins Binding: GoalStartEvent (example): Codes describing events that can trigger the initiation of a goal.
startDate			date S
startCodeableConcept			CodeableConcept
target	SC	0..*	BackboneElement	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		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 Practitioner Profile S | US Core Patient Profile | PractitionerRole | US Core RelatedPerson Profile)	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	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.priority	preferred	GoalPriority http://hl7.org/fhir/ValueSet/goal-priority from the FHIR Standard
Goal.description	preferred	USCoreGoalCodes http://hl7.org/fhir/us/core/ValueSet/us-core-goal-description from this IG
Goal.start[x]	example	GoalStartEvent http://hl7.org/fhir/ValueSet/goal-start-event from the FHIR Standard
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

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 (preferred): Value set to describe the Goal Additional Bindings Purpose Social Determinants of Health Goals Preferred
subject	S	1..1	Reference(US Core Patient Profile S | Group | Organization)	Who this goal is intended for
start[x]	S	0..1		When goal pursuit begins
startDate			date S
startCodeableConcept			CodeableConcept
target	S	0..*	BackboneElement	Target outcome for the goal
due[x]	S	0..1		Reach goal on or before
dueDate			date S
dueDuration			Duration
expressedBy	S	0..1	Reference(US Core Practitioner Profile S | US Core Patient Profile | PractitionerRole | US Core RelatedPerson Profile)	Who's responsible for creating Goal?
Documentation for this format

Terminology Bindings (Differential)

Path	Conformance	ValueSet	URI
Goal.lifecycleStatus	required	GoalLifecycleStatus http://hl7.org/fhir/ValueSet/goal-status from the FHIR Standard
Goal.description	preferred	USCoreGoalCodes http://hl7.org/fhir/us/core/ValueSet/us-core-goal-description from this IG

Key Elements View

Name	Flags	Card.	Type	Description & Constraints
Goal		0..*	Goal	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	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
description	SΣ	1..1	CodeableConcept	Code or text describing goal Binding: US Core Goal Codes (preferred): Value set to describe the Goal Additional Bindings Purpose Social Determinants of Health Goals Preferred ele-1: All FHIR elements must have a @value or children
subject	SΣ	1..1	Reference(US Core Patient Profile)	Who this goal is intended for ele-1: All FHIR elements must have a @value or children
start[x]	SΣ	0..1		When goal pursuit begins Binding: GoalStartEvent (example): Codes describing events that can trigger the initiation of a goal. ele-1: All FHIR elements must have a @value or children
startDate			date
target	SC	0..*	BackboneElement	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		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 Practitioner Profile)	Who's responsible for creating Goal? 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.description	preferred	USCoreGoalCodes http://hl7.org/fhir/us/core/ValueSet/us-core-goal-description from this IG
Goal.start[x]	example	GoalStartEvent http://hl7.org/fhir/ValueSet/goal-start-event from the FHIR Standard

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 (preferred): Value set to describe the Goal Additional Bindings Purpose Social Determinants of Health Goals Preferred
subject	SΣ	1..1	Reference(US Core Patient Profile S | Group | Organization)	Who this goal is intended for
start[x]	SΣ	0..1		When goal pursuit begins Binding: GoalStartEvent (example): Codes describing events that can trigger the initiation of a goal.
startDate			date S
startCodeableConcept			CodeableConcept
target	SC	0..*	BackboneElement	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		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 Practitioner Profile S | US Core Patient Profile | PractitionerRole | US Core RelatedPerson Profile)	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	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.priority	preferred	GoalPriority http://hl7.org/fhir/ValueSet/goal-priority from the FHIR Standard
Goal.description	preferred	USCoreGoalCodes http://hl7.org/fhir/us/core/ValueSet/us-core-goal-description from this IG
Goal.start[x]	example	GoalStartEvent http://hl7.org/fhir/ValueSet/goal-start-event from the FHIR Standard
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 Goal

Summary

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)
• 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)

Maturity: 3

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.

• See the Scopes Format section for a description of the SMART scopes syntax.
• See the Search Syntax section for a description of the US Core search syntax.
• 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.

US Core Scopes

Servers providing access to goal data SHALL support these US Core SMART Scopes:

• resource level scopes: <patient|user|system>/Goal.rs

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)