Scope and usage

In a Danish municipality setting, CommonCareSocialGoal is used to describe all the different kinds of goals and purposes defined by FSIII and FFB. Note that two specialized goal resources exist - use these for “FFB borgers mål og ønsker” og “Indsatsformål” if you want the CommonCareSocialCarePlan to work as intended.

The cateogory-attribute defines the different goals using the KLCommonGoalTypeCodes ValueSet. The goal-type often controls, which of the other attributes that are relevant to use. See more in the section “Bemærkninger vedr. eksempler”

The goal itself is described using Goal.target and/or Goal.description. The target may either be a severity related to functioning, or a changeValue. Goal.target.meassure may also be used to express the method by which a condition is evaluated without providing specific information about target.detail as described for “Indsatsmål” in FSIII (målmetode). The description may supplement the structured information and is used as primary description of the goal for categories that does not include structured data.

Goal.adresses has an extension (ConditionRank), which provide the means to prioritize the Conditions and MatterOfInterest that the goal addresses. The ConditionRank should be used in FFB to express the condition, which the goal primarily addresses (måltilstand), which is equivalent to rank 1. Other Condition or Information resources does not need to specify a rank. FFB only requires a Condition with rank 1 for “FFB Indsatsmål”, relating more conditions and matterOfInteres ressources is optional.

The goal outcome attributes are expressed as required by “FFB Indsatsmål”, with a note about outcome in Goal.outcomeCode.text, and the informer of that outcome stated in Goal.outcomeCode.extention:matterOfInterestInformer. Other than this, the goal outcome is often documented as a change in the condition. However, this is already handled by the Goal.adresses attribute. For reporting use cases, you just need to explicitely state at which points in time you need reporting of Goals and Conditions.

There may be several instanses of annotation stored in Goal.note.text, which describe how working with the goal progresses. Goal.note should be populated with a time and an author whenever relevant. Should not be confused with the Goal.description and Goal.outcomeCode.text.

Note that FFB, for some goals describe, whose goal it is. E.g. “borgers mål og ønsker” should be documented as described by the citizen. However, the Goal.expressedBy attribute should always be populated with the responsible practitioner. If describing the different roles of the documentation process in more detail is needed, use a Provanance resource and set the Goal as Provenance.target.

In Goal.extension:goalRelationship.type.text the string “based-on” define that the goal is based on another more overall goal. Goal.extension:goalRelationship.target references this overall goal. The relationship is used to link sub-goals (delmål) and intervention goals (indsatsmål) in FFB.

Goal.target.measure is used to express the type of observations, that should be performed to follow the goal, E.g. Pressure Ulcer Surface area observations, for goal related to curing an ulcer (FSIII målemetode). Goal.target.measure has a binding to an Observation ValueSet, which may be extended as needed. If possible, extend with observation codes fra SNOMED CT, and report the codes used to Local Government Denmark (KL).

The FHIR Goal ressource has a mandatory attribute Goal.lifecycleStatus with a binding to a status ValueSet. The whole ValueSet may be used, but you may constrain it, and only use “proposed” for all goals that are not yet active, “active” for active goals, and “completed” for all goals that are either reached or no longer being persued.

Bemærkninger vedr. eksempler

Bemærk desuden at denne profil har et eksempel for hver type af mål:

• FSIII tilstandsmål (også kendt som forventet tilstand. Er kyttet til den tilstand der sættes mål for gennem Goal.adresses). Se: JudithForventetTilstand og MarkForventetTilstand
• FSIII indsatsmål (Det FSIII beskriver som udførers indsatsmål, ressourcen rummer også målemetode) Se: MarkIndsatsmaal
• FFB borgers mål og ønsker (Den overordnede beskrivelse der dokumenteres ifm. sagsåbning). Se: AndreasMaalOnsker
• Indsatsformål (Overordnet mål for en FFB social indsats, forventning om at den også kan anvendes for §140 forløb og §119 forløb). Se profilen KLCommonCareSocialPurpose - eksemplerne: AndreasIndsatsformaal og AndreasIndsatsformaal2
• FFB indsatsmål (FFB’s mål med indsatsen, som relaterer sig til de tilstand der sættes mål for ifm en social indsats. Tilstandene relateres gennem Goal.adresses). Se profilen KLCommonCareSocialFFBGoal - eksempel: Andreasindsatsmaal
• FFB delmål (FFB’s udfører mål) Se: AndreasDelmaal

Conversions between Danish information model and FHIR-profile

Nedenstående tabel oversætter mellem de attributter der er defineret i den fælleskommunale informationsmodel (FKI), definerer kort den enkelte attribut på dansk og specificere hvilke af FHIR-profilens atributter, der skal bruges til specifikation af indholdet.

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

This structure is derived from Goal

Name	Flags	Card.	Type	Description & Constraints
Goal			Goal
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
goalRelationship		0..1	(Complex)	Goals related to this Goal URL: http://hl7.org/fhir/StructureDefinition/goal-relationship
extension:type		1..1	Extension	Extension
value[x]		1..1	CodeableConcept	[DK] delmålBaseretPå
text		0..1	string	Plain text representation of the concept Required Pattern: based-on
extension:target		1..1	Extension	Extension
value[x]		1..1	Reference(Goal)	[DK] delmålBaseretPå
category		1..1	CodeableConcept	[DK] målkategori Binding: KLMålKategoriKoder (required)
description		1..1	CodeableConcept	[DK] målbeskrivelse
subject		1..1	Reference(Citizen)	[DK] målSubjekt
Slices for target		0..*	BackboneElement	Target outcome for the goal Slice: Unordered, Open by value:measure
target:All Slices				Content/Rules for all slices
measure		0..1	CodeableConcept	[DK] målemetode Binding: KLTypeAfObservationPåMål (extensible)
target:severitySlice		0..1	BackboneElement	[DK] målSværhedsgrad
measure		1..1	CodeableConcept	The parameter whose value is being tracked Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://kl.dk/fhir/common/caresocial/CodeSystem/KLCommonCareSocialCodes
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 66959f77-6e2a-4574-8423-3ff097f8b9fa
detail[x]		0..1	CodeableConcept	The target value to be achieved Binding: KLSværhedgrader (required)
target:changeValueSlice		0..1	BackboneElement	[DK] måltype
measure		1..1	CodeableConcept	The parameter whose value is being tracked Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://kl.dk/fhir/common/caresocial/CodeSystem/KLCommonCareSocialCodes
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 90c48f03-f194-4b2f-ad7d-6cba1069ae48
detail[x]		0..1	CodeableConcept	The target value to be achieved Binding: KLMåltypeKoder (required)
expressedBy		0..1	Reference(Practioner | Citizen)	[DK] målAnsvarlig
addresses		0..*	Reference(Condition | MatterOfInterest)	[DK] målrelateret
conditionRank		0..1	positiveInt	[DK] målrelateretRang URL: http://kl.dk/fhir/common/caresocial/StructureDefinition/ConditionRank
note
text		1..1	markdown	[DK] målnotat
outcomeCode
matterOfInterestInformer		0..1	CodeableConcept	[DK] målvurderingsInformant URL: http://kl.dk/fhir/common/caresocial/StructureDefinition/MatterOfInterestInformer Binding: KLKildeTilOplysningFFB (required)
text		0..1	string	[DK] målvurdering
Documentation for this format

Terminology Bindings (Differential)

Path	Conformance	ValueSet
Goal.category	required	KLGoalTypeCodes
Goal.target.measure	extensible	KLTargetMeasureCodes
Goal.target:severitySlice.detail[x]	required	KLSeverities
Goal.target:changeValueSlice.detail[x]	required	KLChangeValueCodes

Name	Flags	Card.	Type	Description & Constraints
Goal		0..*	Goal	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
goalRelationship		0..1	(Complex)	Goals related to this Goal URL: http://hl7.org/fhir/StructureDefinition/goal-relationship
Slices for extension		2..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
extension:type		1..1	Extension	Extension
extension		0..0
url		1..1	uri	"type"
value[x]		1..1	CodeableConcept	[DK] delmålBaseretPå Binding: GoalRelationshipType (extensible): Types of relationships between two goals.
text	Σ	0..1	string	Plain text representation of the concept Required Pattern: based-on
extension:target		1..1	Extension	Extension
extension		0..0
url		1..1	uri	"target"
value[x]		1..1	Reference(Goal)	[DK] delmålBaseretPå
url		1..1	uri	"http://hl7.org/fhir/StructureDefinition/goal-relationship"
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
lifecycleStatus	?!Σ	1..1	code	proposed | planned | accepted | active | on-hold | completed | cancelled | entered-in-error | rejected Binding: GoalLifecycleStatus (required): Codes that reflect the current state of a goal and whether the goal is still being targeted.
category	Σ	1..1	CodeableConcept	[DK] målkategori Binding: KLMålKategoriKoder (required)
description	Σ	1..1	CodeableConcept	[DK] målbeskrivelse 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(Citizen)	[DK] målSubjekt
Slices for target	C	0..*	BackboneElement	Target outcome for the goal Slice: Unordered, Open by value:measure
target:All Slices				Content/Rules for all slices
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
measure	ΣC	0..1	CodeableConcept	[DK] målemetode Binding: KLTypeAfObservationPåMål (extensible)
target:severitySlice	C	0..1	BackboneElement	[DK] målSværhedsgrad
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
measure	ΣC	1..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. Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://kl.dk/fhir/common/caresocial/CodeSystem/KLCommonCareSocialCodes
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 66959f77-6e2a-4574-8423-3ff097f8b9fa
detail[x]	ΣC	0..1	CodeableConcept	The target value to be achieved Binding: KLSværhedgrader (required)
target:changeValueSlice	C	0..1	BackboneElement	[DK] måltype
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
measure	ΣC	1..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. Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://kl.dk/fhir/common/caresocial/CodeSystem/KLCommonCareSocialCodes
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 90c48f03-f194-4b2f-ad7d-6cba1069ae48
detail[x]	ΣC	0..1	CodeableConcept	The target value to be achieved Binding: KLMåltypeKoder (required)
expressedBy	Σ	0..1	Reference(Practioner | Citizen)	[DK] målAnsvarlig
addresses		0..*	Reference(Condition | MatterOfInterest)	[DK] målrelateret
conditionRank		0..1	positiveInt	[DK] målrelateretRang URL: http://kl.dk/fhir/common/caresocial/StructureDefinition/ConditionRank
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet / Code
Goal.extension:goalRelationship.extension:type.value[x]	extensible	GoalRelationshipType
Goal.lifecycleStatus	required	GoalLifecycleStatus
Goal.category	required	KLGoalTypeCodes
Goal.description	example	SNOMEDCTClinicalFindings
Goal.target.measure	extensible	KLTargetMeasureCodes
Goal.target:severitySlice.measure	example	Pattern: 66959f77-6e2a-4574-8423-3ff097f8b9fa
Goal.target:severitySlice.detail[x]	required	KLSeverities
Goal.target:changeValueSlice.measure	example	Pattern: 90c48f03-f194-4b2f-ad7d-6cba1069ae48
Goal.target:changeValueSlice.detail[x]	required	KLChangeValueCodes

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
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
goalRelationship		0..1	(Complex)	Goals related to this Goal URL: http://hl7.org/fhir/StructureDefinition/goal-relationship
id		0..1	string	Unique id for inter-element referencing
Slices for extension		2..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
extension:type		1..1	Extension	Extension
id		0..1	string	Unique id for inter-element referencing
extension		0..0
url		1..1	uri	"type"
value[x]		1..1	CodeableConcept	[DK] delmålBaseretPå Binding: GoalRelationshipType (extensible): Types of relationships between two goals.
id		0..1	string	Unique id for inter-element referencing
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	Σ	0..1	string	Plain text representation of the concept Required Pattern: based-on
extension:target		1..1	Extension	Extension
id		0..1	string	Unique id for inter-element referencing
extension		0..0
url		1..1	uri	"target"
value[x]		1..1	Reference(Goal)	[DK] delmålBaseretPå
url		1..1	uri	"http://hl7.org/fhir/StructureDefinition/goal-relationship"
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
identifier		0..*	Identifier	External Ids for this goal
lifecycleStatus	?!Σ	1..1	code	proposed | planned | accepted | active | on-hold | completed | cancelled | entered-in-error | rejected Binding: GoalLifecycleStatus (required): Codes that reflect the current state of a goal and whether the goal is still being targeted.
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	1..1	CodeableConcept	[DK] målkategori Binding: KLMålKategoriKoder (required)
priority	Σ	0..1	CodeableConcept	high-priority | medium-priority | low-priority Binding: GoalPriority (preferred): The level of importance associated with a goal.
description	Σ	1..1	CodeableConcept	[DK] målbeskrivelse 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(Citizen)	[DK] målSubjekt
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
Slices for target	C	0..*	BackboneElement	Target outcome for the goal Slice: Unordered, Open by value:measure
target:All Slices				Content/Rules for all slices
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	[DK] målemetode Binding: KLTypeAfObservationPåMål (extensible)
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]	Σ	0..1		Reach goal on or before
dueDate			date
dueDuration			Duration
target:severitySlice	C	0..1	BackboneElement	[DK] målSværhedsgrad
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	1..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. Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://kl.dk/fhir/common/caresocial/CodeSystem/KLCommonCareSocialCodes
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 66959f77-6e2a-4574-8423-3ff097f8b9fa
display		0..1	string	Representation defined by the system
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
detail[x]	ΣC	0..1	CodeableConcept	The target value to be achieved Binding: KLSværhedgrader (required)
due[x]	Σ	0..1		Reach goal on or before
dueDate			date
dueDuration			Duration
target:changeValueSlice	C	0..1	BackboneElement	[DK] måltype
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	1..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. Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://kl.dk/fhir/common/caresocial/CodeSystem/KLCommonCareSocialCodes
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 90c48f03-f194-4b2f-ad7d-6cba1069ae48
display		0..1	string	Representation defined by the system
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
detail[x]	ΣC	0..1	CodeableConcept	The target value to be achieved Binding: KLMåltypeKoder (required)
due[x]	Σ	0..1		Reach goal on or before
dueDate			date
dueDuration			Duration
statusDate	Σ	0..1	date	When goal status took effect
statusReason		0..1	string	Reason for current status
expressedBy	Σ	0..1	Reference(Practioner | Citizen)	[DK] målAnsvarlig
addresses		0..*	Reference(Condition | MatterOfInterest)	[DK] målrelateret
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
conditionRank		0..1	positiveInt	[DK] målrelateretRang URL: http://kl.dk/fhir/common/caresocial/StructureDefinition/ConditionRank
reference	ΣC	0..1	string	Literal reference, Relative, internal or absolute URL
type	Σ	0..1	uri	Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).
identifier	Σ	0..1	Identifier	Logical reference, when literal reference is not known
display	Σ	0..1	string	Text alternative for the resource
note		0..*	Annotation	Comments about the goal
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
author[x]	Σ	0..1		Individual responsible for the annotation
authorReference			Reference(Practitioner | Patient | RelatedPerson | Organization)
authorString			string
time	Σ	0..1	dateTime	When the annotation was made
text	Σ	1..1	markdown	[DK] målnotat
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".
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
matterOfInterestInformer		0..1	CodeableConcept	[DK] målvurderingsInformant URL: http://kl.dk/fhir/common/caresocial/StructureDefinition/MatterOfInterestInformer Binding: KLKildeTilOplysningFFB (required)
coding	Σ	0..*	Coding	Code defined by a terminology system
text	Σ	0..1	string	[DK] målvurdering
outcomeReference		0..*	Reference(Observation)	Observation that resulted from goal
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet / Code
Goal.language	preferred	CommonLanguages Additional Bindings Purpose AllLanguages Max Binding
Goal.extension:goalRelationship.extension:type.value[x]	extensible	GoalRelationshipType
Goal.lifecycleStatus	required	GoalLifecycleStatus
Goal.achievementStatus	preferred	GoalAchievementStatus
Goal.category	required	KLGoalTypeCodes
Goal.priority	preferred	GoalPriority
Goal.description	example	SNOMEDCTClinicalFindings
Goal.start[x]	example	GoalStartEvent
Goal.target.measure	extensible	KLTargetMeasureCodes
Goal.target.detail[x]	example
Goal.target:severitySlice.measure	example	Pattern: 66959f77-6e2a-4574-8423-3ff097f8b9fa
Goal.target:severitySlice.detail[x]	required	KLSeverities
Goal.target:changeValueSlice.measure	example	Pattern: 90c48f03-f194-4b2f-ad7d-6cba1069ae48
Goal.target:changeValueSlice.detail[x]	required	KLChangeValueCodes
Goal.addresses.type	extensible	ResourceType
Goal.outcomeCode	example	SNOMEDCTClinicalFindings

Differential View

This structure is derived from Goal

Name	Flags	Card.	Type	Description & Constraints
Goal			Goal
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
goalRelationship		0..1	(Complex)	Goals related to this Goal URL: http://hl7.org/fhir/StructureDefinition/goal-relationship
extension:type		1..1	Extension	Extension
value[x]		1..1	CodeableConcept	[DK] delmålBaseretPå
text		0..1	string	Plain text representation of the concept Required Pattern: based-on
extension:target		1..1	Extension	Extension
value[x]		1..1	Reference(Goal)	[DK] delmålBaseretPå
category		1..1	CodeableConcept	[DK] målkategori Binding: KLMålKategoriKoder (required)
description		1..1	CodeableConcept	[DK] målbeskrivelse
subject		1..1	Reference(Citizen)	[DK] målSubjekt
Slices for target		0..*	BackboneElement	Target outcome for the goal Slice: Unordered, Open by value:measure
target:All Slices				Content/Rules for all slices
measure		0..1	CodeableConcept	[DK] målemetode Binding: KLTypeAfObservationPåMål (extensible)
target:severitySlice		0..1	BackboneElement	[DK] målSværhedsgrad
measure		1..1	CodeableConcept	The parameter whose value is being tracked Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://kl.dk/fhir/common/caresocial/CodeSystem/KLCommonCareSocialCodes
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 66959f77-6e2a-4574-8423-3ff097f8b9fa
detail[x]		0..1	CodeableConcept	The target value to be achieved Binding: KLSværhedgrader (required)
target:changeValueSlice		0..1	BackboneElement	[DK] måltype
measure		1..1	CodeableConcept	The parameter whose value is being tracked Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://kl.dk/fhir/common/caresocial/CodeSystem/KLCommonCareSocialCodes
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 90c48f03-f194-4b2f-ad7d-6cba1069ae48
detail[x]		0..1	CodeableConcept	The target value to be achieved Binding: KLMåltypeKoder (required)
expressedBy		0..1	Reference(Practioner | Citizen)	[DK] målAnsvarlig
addresses		0..*	Reference(Condition | MatterOfInterest)	[DK] målrelateret
conditionRank		0..1	positiveInt	[DK] målrelateretRang URL: http://kl.dk/fhir/common/caresocial/StructureDefinition/ConditionRank
note
text		1..1	markdown	[DK] målnotat
outcomeCode
matterOfInterestInformer		0..1	CodeableConcept	[DK] målvurderingsInformant URL: http://kl.dk/fhir/common/caresocial/StructureDefinition/MatterOfInterestInformer Binding: KLKildeTilOplysningFFB (required)
text		0..1	string	[DK] målvurdering
Documentation for this format

Terminology Bindings (Differential)

Path	Conformance	ValueSet
Goal.category	required	KLGoalTypeCodes
Goal.target.measure	extensible	KLTargetMeasureCodes
Goal.target:severitySlice.detail[x]	required	KLSeverities
Goal.target:changeValueSlice.detail[x]	required	KLChangeValueCodes

Key Elements View

Name	Flags	Card.	Type	Description & Constraints
Goal		0..*	Goal	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
goalRelationship		0..1	(Complex)	Goals related to this Goal URL: http://hl7.org/fhir/StructureDefinition/goal-relationship
Slices for extension		2..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
extension:type		1..1	Extension	Extension
extension		0..0
url		1..1	uri	"type"
value[x]		1..1	CodeableConcept	[DK] delmålBaseretPå Binding: GoalRelationshipType (extensible): Types of relationships between two goals.
text	Σ	0..1	string	Plain text representation of the concept Required Pattern: based-on
extension:target		1..1	Extension	Extension
extension		0..0
url		1..1	uri	"target"
value[x]		1..1	Reference(Goal)	[DK] delmålBaseretPå
url		1..1	uri	"http://hl7.org/fhir/StructureDefinition/goal-relationship"
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
lifecycleStatus	?!Σ	1..1	code	proposed | planned | accepted | active | on-hold | completed | cancelled | entered-in-error | rejected Binding: GoalLifecycleStatus (required): Codes that reflect the current state of a goal and whether the goal is still being targeted.
category	Σ	1..1	CodeableConcept	[DK] målkategori Binding: KLMålKategoriKoder (required)
description	Σ	1..1	CodeableConcept	[DK] målbeskrivelse 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(Citizen)	[DK] målSubjekt
Slices for target	C	0..*	BackboneElement	Target outcome for the goal Slice: Unordered, Open by value:measure
target:All Slices				Content/Rules for all slices
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
measure	ΣC	0..1	CodeableConcept	[DK] målemetode Binding: KLTypeAfObservationPåMål (extensible)
target:severitySlice	C	0..1	BackboneElement	[DK] målSværhedsgrad
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
measure	ΣC	1..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. Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://kl.dk/fhir/common/caresocial/CodeSystem/KLCommonCareSocialCodes
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 66959f77-6e2a-4574-8423-3ff097f8b9fa
detail[x]	ΣC	0..1	CodeableConcept	The target value to be achieved Binding: KLSværhedgrader (required)
target:changeValueSlice	C	0..1	BackboneElement	[DK] måltype
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
measure	ΣC	1..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. Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://kl.dk/fhir/common/caresocial/CodeSystem/KLCommonCareSocialCodes
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 90c48f03-f194-4b2f-ad7d-6cba1069ae48
detail[x]	ΣC	0..1	CodeableConcept	The target value to be achieved Binding: KLMåltypeKoder (required)
expressedBy	Σ	0..1	Reference(Practioner | Citizen)	[DK] målAnsvarlig
addresses		0..*	Reference(Condition | MatterOfInterest)	[DK] målrelateret
conditionRank		0..1	positiveInt	[DK] målrelateretRang URL: http://kl.dk/fhir/common/caresocial/StructureDefinition/ConditionRank
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet / Code
Goal.extension:goalRelationship.extension:type.value[x]	extensible	GoalRelationshipType
Goal.lifecycleStatus	required	GoalLifecycleStatus
Goal.category	required	KLGoalTypeCodes
Goal.description	example	SNOMEDCTClinicalFindings
Goal.target.measure	extensible	KLTargetMeasureCodes
Goal.target:severitySlice.measure	example	Pattern: 66959f77-6e2a-4574-8423-3ff097f8b9fa
Goal.target:severitySlice.detail[x]	required	KLSeverities
Goal.target:changeValueSlice.measure	example	Pattern: 90c48f03-f194-4b2f-ad7d-6cba1069ae48
Goal.target:changeValueSlice.detail[x]	required	KLChangeValueCodes

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
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
goalRelationship		0..1	(Complex)	Goals related to this Goal URL: http://hl7.org/fhir/StructureDefinition/goal-relationship
id		0..1	string	Unique id for inter-element referencing
Slices for extension		2..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
extension:type		1..1	Extension	Extension
id		0..1	string	Unique id for inter-element referencing
extension		0..0
url		1..1	uri	"type"
value[x]		1..1	CodeableConcept	[DK] delmålBaseretPå Binding: GoalRelationshipType (extensible): Types of relationships between two goals.
id		0..1	string	Unique id for inter-element referencing
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	Σ	0..1	string	Plain text representation of the concept Required Pattern: based-on
extension:target		1..1	Extension	Extension
id		0..1	string	Unique id for inter-element referencing
extension		0..0
url		1..1	uri	"target"
value[x]		1..1	Reference(Goal)	[DK] delmålBaseretPå
url		1..1	uri	"http://hl7.org/fhir/StructureDefinition/goal-relationship"
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
identifier		0..*	Identifier	External Ids for this goal
lifecycleStatus	?!Σ	1..1	code	proposed | planned | accepted | active | on-hold | completed | cancelled | entered-in-error | rejected Binding: GoalLifecycleStatus (required): Codes that reflect the current state of a goal and whether the goal is still being targeted.
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	1..1	CodeableConcept	[DK] målkategori Binding: KLMålKategoriKoder (required)
priority	Σ	0..1	CodeableConcept	high-priority | medium-priority | low-priority Binding: GoalPriority (preferred): The level of importance associated with a goal.
description	Σ	1..1	CodeableConcept	[DK] målbeskrivelse 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(Citizen)	[DK] målSubjekt
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
Slices for target	C	0..*	BackboneElement	Target outcome for the goal Slice: Unordered, Open by value:measure
target:All Slices				Content/Rules for all slices
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	[DK] målemetode Binding: KLTypeAfObservationPåMål (extensible)
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]	Σ	0..1		Reach goal on or before
dueDate			date
dueDuration			Duration
target:severitySlice	C	0..1	BackboneElement	[DK] målSværhedsgrad
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	1..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. Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://kl.dk/fhir/common/caresocial/CodeSystem/KLCommonCareSocialCodes
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 66959f77-6e2a-4574-8423-3ff097f8b9fa
display		0..1	string	Representation defined by the system
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
detail[x]	ΣC	0..1	CodeableConcept	The target value to be achieved Binding: KLSværhedgrader (required)
due[x]	Σ	0..1		Reach goal on or before
dueDate			date
dueDuration			Duration
target:changeValueSlice	C	0..1	BackboneElement	[DK] måltype
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	1..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. Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://kl.dk/fhir/common/caresocial/CodeSystem/KLCommonCareSocialCodes
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 90c48f03-f194-4b2f-ad7d-6cba1069ae48
display		0..1	string	Representation defined by the system
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
detail[x]	ΣC	0..1	CodeableConcept	The target value to be achieved Binding: KLMåltypeKoder (required)
due[x]	Σ	0..1		Reach goal on or before
dueDate			date
dueDuration			Duration
statusDate	Σ	0..1	date	When goal status took effect
statusReason		0..1	string	Reason for current status
expressedBy	Σ	0..1	Reference(Practioner | Citizen)	[DK] målAnsvarlig
addresses		0..*	Reference(Condition | MatterOfInterest)	[DK] målrelateret
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
conditionRank		0..1	positiveInt	[DK] målrelateretRang URL: http://kl.dk/fhir/common/caresocial/StructureDefinition/ConditionRank
reference	ΣC	0..1	string	Literal reference, Relative, internal or absolute URL
type	Σ	0..1	uri	Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).
identifier	Σ	0..1	Identifier	Logical reference, when literal reference is not known
display	Σ	0..1	string	Text alternative for the resource
note		0..*	Annotation	Comments about the goal
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
author[x]	Σ	0..1		Individual responsible for the annotation
authorReference			Reference(Practitioner | Patient | RelatedPerson | Organization)
authorString			string
time	Σ	0..1	dateTime	When the annotation was made
text	Σ	1..1	markdown	[DK] målnotat
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".
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
matterOfInterestInformer		0..1	CodeableConcept	[DK] målvurderingsInformant URL: http://kl.dk/fhir/common/caresocial/StructureDefinition/MatterOfInterestInformer Binding: KLKildeTilOplysningFFB (required)
coding	Σ	0..*	Coding	Code defined by a terminology system
text	Σ	0..1	string	[DK] målvurdering
outcomeReference		0..*	Reference(Observation)	Observation that resulted from goal
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet / Code
Goal.language	preferred	CommonLanguages Additional Bindings Purpose AllLanguages Max Binding
Goal.extension:goalRelationship.extension:type.value[x]	extensible	GoalRelationshipType
Goal.lifecycleStatus	required	GoalLifecycleStatus
Goal.achievementStatus	preferred	GoalAchievementStatus
Goal.category	required	KLGoalTypeCodes
Goal.priority	preferred	GoalPriority
Goal.description	example	SNOMEDCTClinicalFindings
Goal.start[x]	example	GoalStartEvent
Goal.target.measure	extensible	KLTargetMeasureCodes
Goal.target.detail[x]	example
Goal.target:severitySlice.measure	example	Pattern: 66959f77-6e2a-4574-8423-3ff097f8b9fa
Goal.target:severitySlice.detail[x]	required	KLSeverities
Goal.target:changeValueSlice.measure	example	Pattern: 90c48f03-f194-4b2f-ad7d-6cba1069ae48
Goal.target:changeValueSlice.detail[x]	required	KLChangeValueCodes
Goal.addresses.type	extensible	ResourceType
Goal.outcomeCode	example	SNOMEDCTClinicalFindings

This structure is derived from Goal

Summary

Mandatory: 1 element (2 nested mandatory elements)

Structures

This structure refers to these other structures:

• Goal (http://kl.dk/fhir/common/caresocial/StructureDefinition/KLCommonCareSocialGoal)
• Citizen (http://kl.dk/fhir/common/caresocial/StructureDefinition/KLCommonCitizen)
• Practioner (http://kl.dk/fhir/common/caresocial/StructureDefinition/KLCommonPractitioner)
• Condition (http://kl.dk/fhir/common/caresocial/StructureDefinition/KLCommonCareSocialCondition)
• MatterOfInterest (http://kl.dk/fhir/common/caresocial/StructureDefinition/KLCommonCareSocialMatterOfInterest)

Extensions

This structure refers to these extensions:

• http://hl7.org/fhir/StructureDefinition/goal-relationship
• http://kl.dk/fhir/common/caresocial/StructureDefinition/ConditionRank
• http://kl.dk/fhir/common/caresocial/StructureDefinition/MatterOfInterestInformer

Slices

This structure defines the following Slices:

• The element Goal.target is sliced based on the value of value:measure