The US Core Goal sets minimum expectations for the Goal resource to record, search, and fetch goals associated with a patient, including information about a Social Determinants of Health-related goals. It identifies which core elements, extensions, vocabularies and value sets SHALL be present in the resource when using this profile. In addition to the requirements set forth in US Core Goal this derived profile is designed to add requirements to the following elements:

• Goal.expressedBy (Must Support)
• Goal.addresses (Must Support)
• Goal.outcomeReference (Must Support)
• Goal.extension:goal-acceptance (Must Support)
• Goal.extension:reasonRejected (Must Support)
• Goal.extension:goal-relationship (Must Support)

Although no MCC Goal value sets were developed for this guide beyond what is present in the US Core Goal profile, please see the MCC Goal Value Set library page for terminology and value set guidance specific to this Goal profile.

See the MCC Care Plan SDOH Guidance page for more information when exchanging Social Determinants of Health (SDOH) goals.

Comments are welcome with respect to the pragmatic use of the “Must Support” rules defined on these elements.

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

This structure is derived from USCoreGoalProfile

Name	Flags	Card.	Type	Description & Constraints
Goal		0..*	USCoreGoalProfile	Describes the intended objective(s) for a patient, group or organization
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
goal-acceptance	S	0..*	(Complex)	Information about the acceptance and relative priority assigned to the goal by the patient, practitioners and other stake-holders URL: http://hl7.org/fhir/StructureDefinition/goal-acceptance
reasonRejected	S	0..1	CodeableConcept	The reason the goal was not accepted. Applies only if the status of the goal is rejected URL: http://hl7.org/fhir/StructureDefinition/goal-reasonRejected
relationship	S	0..*	(Complex)	Establishes a relationship between this goal and other goals URL: http://hl7.org/fhir/StructureDefinition/goal-relationship
achievementStatus	S	0..1	CodeableConcept	in-progress | improving | worsening | no-change | achieved | sustaining | not-achieved | no-progress | not-attainable
priority	S	0..1	CodeableConcept	high-priority | medium-priority | low-priority
expressedBy	S	0..1	Reference(Patient | Practitioner | PractitionerRole | RelatedPerson)	Who's responsible for creating Goal?
addresses	S	0..*	Reference(Condition | Observation | MedicationStatement | NutritionOrder | ServiceRequest | RiskAssessment)	Issues addressed by this goal
outcomeReference	S	0..*	Reference(Observation)	Observation that resulted from goal
Documentation for this format

Name	Flags	Card.	Type	Description & Constraints
Goal		0..*	USCoreGoalProfile	Describes the intended objective(s) for a patient, group or organization
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
goal-acceptance	S	0..*	(Complex)	Information about the acceptance and relative priority assigned to the goal by the patient, practitioners and other stake-holders URL: http://hl7.org/fhir/StructureDefinition/goal-acceptance
reasonRejected	S	0..1	CodeableConcept	The reason the goal was not accepted. Applies only if the status of the goal is rejected URL: http://hl7.org/fhir/StructureDefinition/goal-reasonRejected
relationship	S	0..*	(Complex)	Establishes a relationship between this goal and other goals URL: http://hl7.org/fhir/StructureDefinition/goal-relationship
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
lifecycleStatus	?!SΣ	1..1	code	(USCDI) proposed | planned | accepted | active | on-hold | completed | cancelled | entered-in-error | rejected Binding: GoalLifecycleStatus (required)
achievementStatus	SΣ	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.
priority	SΣ	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	0..1		(USCDI) When goal pursuit begins Binding: GoalStartEvent (example): Codes describing events that can trigger the initiation of a goal.
startDate			date
target	SC	0..*	BackboneElement	(USCDI) Target outcome for the goal
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
due[x]	SΣ	0..1		(USCDI) Reach goal on or before
dueDate			date
expressedBy	SΣ	0..1	Reference(Patient | Practitioner | PractitionerRole | RelatedPerson)	Who's responsible for creating Goal?
addresses	S	0..*	Reference(Condition | Observation | MedicationStatement | NutritionOrder | ServiceRequest | RiskAssessment)	Issues addressed by this goal
outcomeReference	S	0..*	Reference(Observation)	Observation that resulted from goal
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet
Goal.lifecycleStatus	required	GoalLifecycleStatus
Goal.achievementStatus	preferred	GoalAchievementStatus
Goal.priority	preferred	GoalPriority
Goal.description	extensible	USCoreGoalCodes
Goal.start[x]	example	GoalStartEvent

Constraints

Id	Grade	Path(s)	Details	Requirements
dom-2	error	Goal	If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty()
dom-3	error	Goal	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 : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4	error	Goal	If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5	error	Goal	If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty()
dom-6	best practice	Goal	A resource should have narrative for robust management : text.`div`.exists()
ele-1	error	**ALL** elements	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ext-1	error	**ALL** extensions	Must have either extensions or value[x], not both : extension.exists() != value.exists()
gol-1	error	Goal.target	Goal.target.measure is required if Goal.target.detail is populated : (detail.exists() and measure.exists()) or detail.exists().not()

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
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
goal-acceptance	S	0..*	(Complex)	Information about the acceptance and relative priority assigned to the goal by the patient, practitioners and other stake-holders URL: http://hl7.org/fhir/StructureDefinition/goal-acceptance
reasonRejected	S	0..1	CodeableConcept	The reason the goal was not accepted. Applies only if the status of the goal is rejected URL: http://hl7.org/fhir/StructureDefinition/goal-reasonRejected
relationship	S	0..*	(Complex)	Establishes a relationship between this goal and other goals URL: http://hl7.org/fhir/StructureDefinition/goal-relationship
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	SΣ	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	SΣ	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	0..1		(USCDI) 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	(USCDI) 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	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: (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		(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(Patient | Practitioner | PractitionerRole | RelatedPerson)	Who's responsible for creating Goal?
addresses	S	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	S	0..*	Reference(Observation)	Observation that resulted from goal
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet
Goal.language	preferred	CommonLanguages Additional Bindings Purpose AllLanguages Max Binding
Goal.lifecycleStatus	required	GoalLifecycleStatus
Goal.achievementStatus	preferred	GoalAchievementStatus
Goal.category	example	GoalCategory
Goal.priority	preferred	GoalPriority
Goal.description	extensible	USCoreGoalCodes
Goal.start[x]	example	GoalStartEvent
Goal.target.measure	example	LOINCCodes (a valid code from LOINC)
Goal.target.detail[x]	example
Goal.outcomeCode	example	SNOMEDCTClinicalFindings

Constraints

Id	Grade	Path(s)	Details	Requirements
ele-1	error	**ALL** elements	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ext-1	error	**ALL** extensions	Must have either extensions or value[x], not both : extension.exists() != value.exists()
gol-1	error	Goal.target	Goal.target.measure is required if Goal.target.detail is populated : (detail.exists() and measure.exists()) or detail.exists().not()

Differential View

This structure is derived from USCoreGoalProfile

Name	Flags	Card.	Type	Description & Constraints
Goal		0..*	USCoreGoalProfile	Describes the intended objective(s) for a patient, group or organization
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
goal-acceptance	S	0..*	(Complex)	Information about the acceptance and relative priority assigned to the goal by the patient, practitioners and other stake-holders URL: http://hl7.org/fhir/StructureDefinition/goal-acceptance
reasonRejected	S	0..1	CodeableConcept	The reason the goal was not accepted. Applies only if the status of the goal is rejected URL: http://hl7.org/fhir/StructureDefinition/goal-reasonRejected
relationship	S	0..*	(Complex)	Establishes a relationship between this goal and other goals URL: http://hl7.org/fhir/StructureDefinition/goal-relationship
achievementStatus	S	0..1	CodeableConcept	in-progress | improving | worsening | no-change | achieved | sustaining | not-achieved | no-progress | not-attainable
priority	S	0..1	CodeableConcept	high-priority | medium-priority | low-priority
expressedBy	S	0..1	Reference(Patient | Practitioner | PractitionerRole | RelatedPerson)	Who's responsible for creating Goal?
addresses	S	0..*	Reference(Condition | Observation | MedicationStatement | NutritionOrder | ServiceRequest | RiskAssessment)	Issues addressed by this goal
outcomeReference	S	0..*	Reference(Observation)	Observation that resulted from goal
Documentation for this format

Key Elements View

Name	Flags	Card.	Type	Description & Constraints
Goal		0..*	USCoreGoalProfile	Describes the intended objective(s) for a patient, group or organization
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
goal-acceptance	S	0..*	(Complex)	Information about the acceptance and relative priority assigned to the goal by the patient, practitioners and other stake-holders URL: http://hl7.org/fhir/StructureDefinition/goal-acceptance
reasonRejected	S	0..1	CodeableConcept	The reason the goal was not accepted. Applies only if the status of the goal is rejected URL: http://hl7.org/fhir/StructureDefinition/goal-reasonRejected
relationship	S	0..*	(Complex)	Establishes a relationship between this goal and other goals URL: http://hl7.org/fhir/StructureDefinition/goal-relationship
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
lifecycleStatus	?!SΣ	1..1	code	(USCDI) proposed | planned | accepted | active | on-hold | completed | cancelled | entered-in-error | rejected Binding: GoalLifecycleStatus (required)
achievementStatus	SΣ	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.
priority	SΣ	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	0..1		(USCDI) When goal pursuit begins Binding: GoalStartEvent (example): Codes describing events that can trigger the initiation of a goal.
startDate			date
target	SC	0..*	BackboneElement	(USCDI) Target outcome for the goal
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
due[x]	SΣ	0..1		(USCDI) Reach goal on or before
dueDate			date
expressedBy	SΣ	0..1	Reference(Patient | Practitioner | PractitionerRole | RelatedPerson)	Who's responsible for creating Goal?
addresses	S	0..*	Reference(Condition | Observation | MedicationStatement | NutritionOrder | ServiceRequest | RiskAssessment)	Issues addressed by this goal
outcomeReference	S	0..*	Reference(Observation)	Observation that resulted from goal
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet
Goal.lifecycleStatus	required	GoalLifecycleStatus
Goal.achievementStatus	preferred	GoalAchievementStatus
Goal.priority	preferred	GoalPriority
Goal.description	extensible	USCoreGoalCodes
Goal.start[x]	example	GoalStartEvent

Constraints

Id	Grade	Path(s)	Details	Requirements
dom-2	error	Goal	If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty()
dom-3	error	Goal	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 : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4	error	Goal	If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5	error	Goal	If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty()
dom-6	best practice	Goal	A resource should have narrative for robust management : text.`div`.exists()
ele-1	error	**ALL** elements	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ext-1	error	**ALL** extensions	Must have either extensions or value[x], not both : extension.exists() != value.exists()
gol-1	error	Goal.target	Goal.target.measure is required if Goal.target.detail is populated : (detail.exists() and measure.exists()) or detail.exists().not()

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
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
goal-acceptance	S	0..*	(Complex)	Information about the acceptance and relative priority assigned to the goal by the patient, practitioners and other stake-holders URL: http://hl7.org/fhir/StructureDefinition/goal-acceptance
reasonRejected	S	0..1	CodeableConcept	The reason the goal was not accepted. Applies only if the status of the goal is rejected URL: http://hl7.org/fhir/StructureDefinition/goal-reasonRejected
relationship	S	0..*	(Complex)	Establishes a relationship between this goal and other goals URL: http://hl7.org/fhir/StructureDefinition/goal-relationship
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	SΣ	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	SΣ	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	0..1		(USCDI) 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	(USCDI) 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	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: (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		(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(Patient | Practitioner | PractitionerRole | RelatedPerson)	Who's responsible for creating Goal?
addresses	S	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	S	0..*	Reference(Observation)	Observation that resulted from goal
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet
Goal.language	preferred	CommonLanguages Additional Bindings Purpose AllLanguages Max Binding
Goal.lifecycleStatus	required	GoalLifecycleStatus
Goal.achievementStatus	preferred	GoalAchievementStatus
Goal.category	example	GoalCategory
Goal.priority	preferred	GoalPriority
Goal.description	extensible	USCoreGoalCodes
Goal.start[x]	example	GoalStartEvent
Goal.target.measure	example	LOINCCodes (a valid code from LOINC)
Goal.target.detail[x]	example
Goal.outcomeCode	example	SNOMEDCTClinicalFindings

Constraints

Id	Grade	Path(s)	Details	Requirements
ele-1	error	**ALL** elements	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ext-1	error	**ALL** extensions	Must have either extensions or value[x], not both : extension.exists() != value.exists()
gol-1	error	Goal.target	Goal.target.measure is required if Goal.target.detail is populated : (detail.exists() and measure.exists()) or detail.exists().not()

This structure is derived from USCoreGoalProfile

Summary

Must-Support: 8 elements

Extensions

This structure refers to these extensions:

• http://hl7.org/fhir/StructureDefinition/goal-acceptance
• http://hl7.org/fhir/StructureDefinition/goal-reasonRejected
• http://hl7.org/fhir/StructureDefinition/goal-relationship