Path | Short | Definition | Comments |
---|---|---|---|
Describes the intended objective(s) for a patient, group or organization | Describes the intended objective(s) for a patient, group or organization care, for example, weight loss, restoring an activity of daily living, obtaining herd immunity via immunization, meeting a process improvement objective, etc. | Goal can be achieving a particular change or merely maintaining a current state or even slowing a decline. | |
identifier | External Ids for this goal | Business identifiers assigned to this goal by the performer or other systems which remain constant as the resource is updated and propagates from server to server. | This is a business identifier, not a resource identifier (see [discussion](resource.html#identifiers)). It is best practice for the identifier to only appear on a single resource instance, however business practices may occasionally dictate that multiple resource instances with the same identifier can exist - possibly even with different resource types. For example, multiple Patient and a Person resource instance might share the same social insurance number. |
lifecycleStatus | proposed | planned | accepted | active | on-hold | completed | cancelled | entered-in-error | rejected | The state of the goal throughout its lifecycle. | This element is labeled as a modifier because the lifecycleStatus contains codes that mark the resource as not currently valid. |
achievementStatus | in-progress | improving | worsening | no-change | achieved | sustaining | not-achieved | no-progress | not-attainable | Describes the progression, or lack thereof, towards the goal against the target. | |
category | E.g. Treatment, dietary, behavioral, etc. | Indicates a category the goal falls within. | |
priority | high-priority | medium-priority | low-priority | Identifies the mutually agreed level of importance associated with reaching/sustaining the goal. | Extensions are available to track priorities as established by each participant (i.e. Priority from the patient's perspective, different practitioners' perspectives, family member's perspectives) The ordinal extension on Coding can be used to convey a numerically comparable ranking to priority. (Keep in mind that different coding systems may use a "low value=important". |
description | Code or text describing goal | Human-readable and/or coded description of a specific desired objective of care, such as "control blood pressure" or "negotiate an obstacle course" or "dance with child at wedding". | If no code is available, use CodeableConcept.text. |
subject | Who this goal is intended for | Identifies the patient, group or organization for whom the goal is being established. | |
start[x] | When goal pursuit begins | The date or event after which the goal should begin being pursued. | |
target | Target outcome for the goal | Indicates what should be done by when. | When multiple targets are present for a single goal instance, all targets must be met for the overall goal to be met. |
target.id | Unique id for inter-element referencing | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | |
target.extension | Additional content defined by implementations | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
target.modifierExtension | Extensions that cannot be ignored even if unrecognized | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
target.measure | The parameter whose value is being tracked | The parameter whose value is being tracked, e.g. body weight, blood pressure, or hemoglobin A1c level. | |
target.detail[x] | The target value to be achieved | The target value of the focus to be achieved to signify the fulfillment of the goal, e.g. 150 pounds, 7.0%. Either the high or low or both values of the range can be specified. When a low value is missing, it indicates that the goal is achieved at any focus value at or below the high value. Similarly, if the high value is missing, it indicates that the goal is achieved at any focus value at or above the low value. | A CodeableConcept with just a text would be used instead of a string if the field was usually coded, or if the type associated with the Goal.target.measure defines a coded value. |
target.due[x] | Reach goal on or before | Indicates either the date or the duration after start by which the goal should be met. | |
statusDate | When goal status took effect | Identifies when the current status. I.e. When initially created, when achieved, when cancelled, etc. | To see the date for past statuses, query history. |
statusReason | Reason for current status | Captures the reason for the current status. | This will typically be captured for statuses such as rejected, on-hold or cancelled, but could be present for others. |
expressedBy | Who's responsible for creating Goal? | Indicates whose goal this is - patient goal, practitioner goal, etc. | This is the individual responsible for establishing the goal, not necessarily who recorded it. (For that, use the Provenance resource.). |
addresses | Issues addressed by this goal | The identified conditions and other health record elements that are intended to be addressed by the goal. | |
note | Comments about the goal | Any comments related to the goal. | May be used for progress notes, concerns or other related information that doesn't actually describe the goal itself. |
outcomeCode | What result was achieved regarding the goal? | Identifies the change (or lack of change) at the point when the status of the goal is assessed. | Note that this should not duplicate the goal status. |
outcomeReference | Observation that resulted from goal | Details of what's changed (or not changed). | The goal outcome is independent of the outcome of the related activities. For example, if the Goal is to achieve a target body weight of 150 lb and a care plan activity is defined to diet, then the care plan’s activity outcome could be calories consumed whereas goal outcome is an observation for the actual body weight measured. |
A Goal in health care services delivery is generally an expressed desired health state to be achieved by a subject of care (or family/group) over a period or at a specific point of time. This desired target health state may be achieved as a result of health care intervention(s) or resulting from natural recovery over time. For example:
Goals may address the prevention of illness, cure or mitigation of a condition, prolongation of life, or mitigation of pain and discomfort.
When dealing with groups, goals may also reflect health state, such as a reduction of addiction behaviors. However, they may also reflect population health objectives such as education, screening, etc.
Organizational goals are typically not health state specific but may instead identify measurement targets such as infection control, cost management, patient satisfaction, etc.
Goals are typically established in the context of a CarePlan. However, goals may also be directly referenced by request-type resources (e.g. MedicationRequest or ServiceRequest) by using an extension.
A goal represents a specific goal instance for a particular patient, group, etc. It is not intended to be used to define types of potential goals as part of an order set or protocol definition. Protocol definitions and order sets are supported through PlanDefinition. The Goal resource is intended to be used once an order set is instantiated or assigned to a patient, which is when the potential goals become the actual goals, if not changed or deleted.
Goals are often evaluated using Observations.
achievement-status | in-progress | improving | worsening | no-change | achieved | sustaining | not-achieved | no-progress | not-attainable | Goal.achievementStatus |
category | E.g. Treatment, dietary, behavioral, etc. | Goal.category |
lifecycle-status | proposed | planned | accepted | active | on-hold | completed | cancelled | entered-in-error | rejected | Goal.lifecycleStatus |
start-date | When goal pursuit begins | (Goal.start as date) |
subject | Who this goal is intended for | Goal.subject |
target-date | Reach goal on or before | (Goal.target.due as date) |