PACIO Advance Directive Interoperability Implementation Guide
0.1.0 - STU 1 Ballot

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## Resource Profile: ADI Goal

Defining URL: | http://hl7.org/fhir/us/pacio-adi/StructureDefinition/PADI-Goal
Version: | 0.1.0
Name: | PADIGoal
Title: | ADI Goal
Status: | Active as of 12/6/21 8:50 PM
Definition: | This profile defines the base requirements for all ADI Goals.
Publisher: | HL7 Patient Empowerment Working Group
Source Resource: | XML / JSON / Turtle

The official URL for this profile is:

    http://hl7.org/fhir/us/pacio-adi/StructureDefinition/PADI-Goal

The ADI goal represents the patient’s advance healthcare decision goals for the medical interventions that will be part of the clinician-authored care plan that will drive treatment. The patient’s documented goals of the medical care they will receive is based on the context or condition specified, and is intended to guide the provider-authored interventions that will be documented by the care team providing the treatment interventions that meet those documented patient goals. This allows a person-centered approach to care planning that reflects the specific goals, preferences, and priorities of that person which can then be merged with the clinical care plan so as to enable a jointly developed plan of care between the provider and person receiving care.

### Formal Views of Profile Content

Description of Profiles, Differentials, Snapshots and how the different presentations work.

- Text Summary
- Differential Table
- Snapshot Table
- Snapshot Table (Must Support)
- All

This structure is derived from USCoreGoalProfile

Summary

Mandatory: 2 elements
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)

Extensions

This structure refers to these extensions:

- http://hl7.org/fhir/us/pacio-adi/StructureDefinition/padi-contextualValue-extension

This structure is derived from USCoreGoalProfile

Name | Flags | Card. | Type | Description & Constraints
--- | --- | --- | --- | ---
Goal | I | 0..* | USCoreGoalProfile | This is an abstract profile Describes the intended objective(s) for a patient, group or organization goal-subject-expressedby: subject and expressedBy refer to the same patient
text | S | 1..1 | Narrative | Text summary of the resource, for human interpretation
category | S | 0..* | CodeableConcept | E.g. Treatment, dietary, behavioral, etc.
text | S | 0..1 | string | Plain text representation of the concept
description |  |  |  |
padi-contextualValue-extension |  | 0..1 | (Complex) | Contextual Value URL: http://hl7.org/fhir/us/pacio-adi/StructureDefinition/padi-contextualValue-extension
target |  |  |  |
measure | S | 0..1 | CodeableConcept | The parameter whose value is being tracked
detail[x] | S | 0..1 | Quantity, Range, CodeableConcept, string, boolean, integer, Ratio | The target value to be achieved
expressedBy | S | 1..1 | Reference(US Core Patient Profile) | Who's responsible for creating Goal?
note | S | 0..* | Annotation | Comments about the goal
Documentation for this format

Name | Flags | Card. | Type | Description & Constraints
--- | --- | --- | --- | ---
Goal | I | 0..* | USCoreGoalProfile | This is an abstract profile Describes the intended objective(s) for a patient, group or organization goal-subject-expressedby: subject and expressedBy refer to the same patient
id | Σ | 0..1 | string | 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) Max Binding: AllLanguages: A human language.
text | S | 1..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 | ?!S Σ | 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 | S Σ | 0..* | CodeableConcept | E.g. Treatment, dietary, behavioral, etc. Binding: GoalCategory (example): Codes for grouping and sorting goals.
id |  | 0..1 | string | Unique id for inter-element referencing
Slices for extension |  | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url
coding | Σ | 0..* | Coding | Code defined by a terminology system
text | S Σ | 0..1 | string | Plain text representation of the concept
priority | Σ | 0..1 | CodeableConcept | high-priority | medium-priority | low-priority Binding: GoalPriority (preferred): The level of importance associated with a goal.
description | S Σ | 1..1 | CodeableConcept | Code or text describing goal Binding: SNOMEDCTClinicalFindings (example): Codes providing the details of a particular goal. This will generally be system or implementation guide-specific. In many systems, only the text element will be used.
id |  | 0..1 | string | Unique id for inter-element referencing
Slices for extension |  | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url
padi-contextualValue-extension |  | 0..1 | (Complex) | Contextual Value URL: http://hl7.org/fhir/us/pacio-adi/StructureDefinition/padi-contextualValue-extension
coding | Σ | 0..* | Coding | Code defined by a terminology system
text | Σ | 0..1 | string | Plain text representation of the concept
subject | S Σ | 1..1 | Reference(US Core Patient Profile) | Who this goal is intended for
start[x] | Σ | 0..1 |  | When goal pursuit begins Binding: GoalStartEvent (example): Codes describing events that can trigger the initiation of a goal.
startDate |  |  | date |
startCodeableConcept |  |  | CodeableConcept |
target | S I | 0..* | BackboneElement | 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 | S Σ I | 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] | S Σ I | 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] | S Σ | 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 | S Σ | 1..1 | Reference(US Core Patient Profile) | Who's responsible for creating Goal?
addresses |  | 0..* | Reference(Condition | Observation | MedicationStatement | NutritionOrder | ServiceRequest | RiskAssessment) | Issues addressed by this goal
note | S | 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

Name | Flags | Card. | Type | Description & Constraints
--- | --- | --- | --- | ---
Goal | I | 0..* | USCoreGoalProfile | This is an abstract profile Describes the intended objective(s) for a patient, group or organization goal-subject-expressedby: subject and expressedBy refer to the same patient
text |  | 1..1 | Narrative | Text summary of the resource, for human interpretation
lifecycleStatus | ?!Σ | 1..1 | code | proposed | planned | accepted | active | on-hold | completed | cancelled | entered-in-error | rejected Binding: GoalLifecycleStatus (required)
category | Σ | 0..* | CodeableConcept | E.g. Treatment, dietary, behavioral, etc. Binding: GoalCategory (example): Codes for grouping and sorting goals.
text | Σ | 0..1 | string | Plain text representation of the concept
description | Σ | 1..1 | CodeableConcept | Code or text describing goal Binding: SNOMEDCTClinicalFindings (example): Codes providing the details of a particular goal. This will generally be system or implementation guide-specific. In many systems, only the text element will be used.
subject | Σ | 1..1 | Reference(US Core Patient Profile) | Who this goal is intended for
target | I | 0..* | BackboneElement | Target outcome for the goal
measure | Σ I | 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] | Σ I | 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] | Σ | 0..1 |  | Reach goal on or before
dueDate |  |  | date |
expressedBy | Σ | 1..1 | Reference(US Core Patient Profile) | Who's responsible for creating Goal?
note |  | 0..* | Annotation | Comments about the goal
Documentation for this format

This structure is derived from USCoreGoalProfile

Summary

Mandatory: 2 elements
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)

Extensions

This structure refers to these extensions:

- http://hl7.org/fhir/us/pacio-adi/StructureDefinition/padi-contextualValue-extension

Differential View

This structure is derived from USCoreGoalProfile

Name | Flags | Card. | Type | Description & Constraints
--- | --- | --- | --- | ---
Goal | I | 0..* | USCoreGoalProfile | This is an abstract profile Describes the intended objective(s) for a patient, group or organization goal-subject-expressedby: subject and expressedBy refer to the same patient
text | S | 1..1 | Narrative | Text summary of the resource, for human interpretation
category | S | 0..* | CodeableConcept | E.g. Treatment, dietary, behavioral, etc.
text | S | 0..1 | string | Plain text representation of the concept
description |  |  |  |
padi-contextualValue-extension |  | 0..1 | (Complex) | Contextual Value URL: http://hl7.org/fhir/us/pacio-adi/StructureDefinition/padi-contextualValue-extension
target |  |  |  |
measure | S | 0..1 | CodeableConcept | The parameter whose value is being tracked
detail[x] | S | 0..1 | Quantity, Range, CodeableConcept, string, boolean, integer, Ratio | The target value to be achieved
expressedBy | S | 1..1 | Reference(US Core Patient Profile) | Who's responsible for creating Goal?
note | S | 0..* | Annotation | Comments about the goal
Documentation for this format

Snapshot View

Name | Flags | Card. | Type | Description & Constraints
--- | --- | --- | --- | ---
Goal | I | 0..* | USCoreGoalProfile | This is an abstract profile Describes the intended objective(s) for a patient, group or organization goal-subject-expressedby: subject and expressedBy refer to the same patient
id | Σ | 0..1 | string | 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) Max Binding: AllLanguages: A human language.
text | S | 1..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 | ?!S Σ | 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 | S Σ | 0..* | CodeableConcept | E.g. Treatment, dietary, behavioral, etc. Binding: GoalCategory (example): Codes for grouping and sorting goals.
id |  | 0..1 | string | Unique id for inter-element referencing
Slices for extension |  | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url
coding | Σ | 0..* | Coding | Code defined by a terminology system
text | S Σ | 0..1 | string | Plain text representation of the concept
priority | Σ | 0..1 | CodeableConcept | high-priority | medium-priority | low-priority Binding: GoalPriority (preferred): The level of importance associated with a goal.
description | S Σ | 1..1 | CodeableConcept | Code or text describing goal Binding: SNOMEDCTClinicalFindings (example): Codes providing the details of a particular goal. This will generally be system or implementation guide-specific. In many systems, only the text element will be used.
id |  | 0..1 | string | Unique id for inter-element referencing
Slices for extension |  | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url
padi-contextualValue-extension |  | 0..1 | (Complex) | Contextual Value URL: http://hl7.org/fhir/us/pacio-adi/StructureDefinition/padi-contextualValue-extension
coding | Σ | 0..* | Coding | Code defined by a terminology system
text | Σ | 0..1 | string | Plain text representation of the concept
subject | S Σ | 1..1 | Reference(US Core Patient Profile) | Who this goal is intended for
start[x] | Σ | 0..1 |  | When goal pursuit begins Binding: GoalStartEvent (example): Codes describing events that can trigger the initiation of a goal.
startDate |  |  | date |
startCodeableConcept |  |  | CodeableConcept |
target | S I | 0..* | BackboneElement | 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 | S Σ I | 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] | S Σ I | 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] | S Σ | 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 | S Σ | 1..1 | Reference(US Core Patient Profile) | Who's responsible for creating Goal?
addresses |  | 0..* | Reference(Condition | Observation | MedicationStatement | NutritionOrder | ServiceRequest | RiskAssessment) | Issues addressed by this goal
note | S | 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

Other representations of profile: CSV, Excel, Schematron

#### Terminology Bindings

Path | Conformance | ValueSet
Goal.language | preferred | CommonLanguages Max Binding: AllLanguages
Goal.lifecycleStatus | required | GoalLifecycleStatus
Goal.achievementStatus | preferred | GoalAchievementStatus
Goal.category | example | GoalCategory
Goal.priority | preferred | GoalPriority
Goal.description | example | SNOMEDCTClinicalFindings
Goal.start[x] | example | GoalStartEvent
Goal.target.measure | example | LOINCCodes
Goal.target.detail[x] | example |
Goal.outcomeCode | example | SNOMEDCTClinicalFindings

#### Constraints

Id | Path | Details | Requirements
goal-subject-expressedby | Goal | subject and expressedBy refer to the same patient : subject = expressedBy |