A Goal is a desired health state, outcome, or objective that a patient, practitioner wishes to achieve. At its core, it represents targeted outcomes for a patient's health status, functional status, or specific health behaviors.

Key Purpose

• Define and track desired healthcare outcomes
• Support care planning and progress monitoring
• Enable shared decision-making between providers and patients
• Facilitate outcome-based healthcare delivery
• Document patient preferences and priorities

Resource Structure

Goals can be both high-level aspirational targets and specific measurable objectives. The resource supports both qualitative and quantitative targets.

Version 1

{
  "identifier": "<uuid4>",  // Unique identifier for this goal
  "lifecycleStatus": "option", // proposed | planned | accepted | active | on-hold | completed | cancelled | entered-in-error | rejected
  "achievementStatus": "option",  // in-progress | improving | worsening | achieved | not-achieved | sustaining | not-attainable
  "category": [
    { "system": "str", "code": "str", "display": "str" }
  ], // Categories like dietary, safety, behavioral, nursing, physiotherapy <https://hl7.org/fhir/valueset-goal-category.html>
  "priority": "option", // high | medium | low
  "description": "text", // The goal title and description
  "subject": "patient_id" // Patient Id in care
  "startDate": "dateTime",  // When goal pursuit begins
  "target": [
	  {  // The target outcome or value to achieve
	    "measure": { "system": "str", "code": "str", "display": "str" } // Use Loinc
	    "detailString": "string", // Target description, can be expanded later to support other types. 
	    "dueDate": "dateTime"  // When goal should be met
	  }
  ],
  "statusDate": "dateTime",  // When status last changed
  "statusReason": "string",  // Reason for current status
	"note": [
		{ // Can be used to log updates 
			"authorReference": "id|fk", // Who made the note
			"time": "datetime",
			"text": "str" // Free text for any clinical notes related to the encounter.
		}
	],
  "outcomeCode": [ 
		{ "system": "SNOMED-CT", "code": "str", "display": "str" }], // 'Clinical finding' from SNOMED CT (concept code: 404684003)
	]
}

Implementation Notes

• Consider implementing goal templates for common scenarios
• Support both short-term and long-term goals

Implementation Example

Consider a diabetic patient working to lower their HbA1c levels:

sequenceDiagram
    participant P as Patient
    participant D as Doctor
    participant G as Goal
    participant O as Observation
    participant CP as CarePlan

    D->>G: Creates HbA1c goal (target: 7.0%)
    G->>P: Goal proposed to patient
    P->>G: Patient accepts goal
    G->>CP: Goal linked to care plan
    CP->>G: Care activities defined
    O->>G: Regular HbA1c readings recorded
    Note over G: Status updates based on readings by doctor
    G->>D: Progress monitored
    G->>P: Achievement status tracked