Id2.16.840.1.113883.10.20.22.4.121Effective Date2015‑08‑13
Statusdraft DraftVersion Label2.1
NameGoalObservationDisplay NameGoal Observation
Description
This template represents a patient health goal. A Goal Observation template may have related components that are acts, encounters, observations, procedures, substance administrations, or supplies. A goal may be a patient or provider goal. If the author is set to the recordTarget (patient), this is a patient goal. If the author is set to a provider, this is a provider goal. If both patient and provider are set as authors, this is a negotiated goal. A goal usually has a related health concern and/or risk. A goal may have components consisting of other goals (milestones). These milestones are related to the overall goal through entryRelationships.
ContextParent nodes of template element with id 2.16.840.1.113883.10.20.22.4.121
ClassificationCDA Entry Level Template
Open/ClosedOpen (other than defined elements are allowed)
Used by / Uses
Used by 10 transactions and 15 templates, Uses 5 templates
Used by as NameVersion
2.16.840.1.113883.3.1937.99.3.4.27Transactionfinal Operative Note (V3)2015‑08‑01
2.16.840.1.113883.3.1937.99.3.4.31Transactionfinal Transfer Summary (V2)2015‑08‑01
2.16.840.1.113883.3.1937.99.3.4.25Transactionfinal Discharge Summary (V3)2015‑08‑01
2.16.840.1.113883.3.1937.99.3.4.29Transactionfinal Progress Note (V3)2015‑08‑01
2.16.840.1.113883.3.1937.99.3.4.26Transactionfinal History and Physical (V3)2015‑08‑01
2.16.840.1.113883.3.1937.99.3.4.22Transactionfinal Consultation Note (V3)2015‑08‑01
2.16.840.1.113883.3.1937.99.3.4.28Transactionfinal Procedure Note (V3)2015‑08‑01
2.16.840.1.113883.3.1937.99.3.4.23Transactionfinal Continuity of Care Document (CCD) (V3)2015‑08‑01
2.16.840.1.113883.3.1937.99.3.4.30Transactionfinal Referral Note (V2)2015‑08‑01
2.16.840.1.113883.3.1937.99.3.4.21Transactionfinal Care Plan (V2)2015‑08‑01
2.16.840.1.113883.3.1937.99.61.26.10.125Containmentdraft Goal Observation (2.1)2019‑04‑29 09:26:00
2.16.840.1.113883.10.20.22.1.2linkdraft Continuity of Care Document (CCD) (V3) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.22.1.3linkdraft History and Physical (V3) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.22.1.4linkdraft Consultation Note (V3) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.22.1.6linkdraft Procedure Note (V3) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.22.1.7linkdraft Operative Note (V3) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.22.1.8linkdraft Discharge Summary (V3) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.22.1.9linkdraft Progress Note (V3) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.22.1.13linkdraft Transfer Summary (V2) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.22.1.14linkdraft Referral Note (V2) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.22.1.15linkdraft Care Plan (V2) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.22.2.10Containmentdraft Plan of Treatment Section (V2) (2.1)2014‑06‑09
2.16.840.1.113883.10.20.22.2.10Containmentdraft Plan of Treatment Section (V2) (2.1)2019‑03‑16 08:54:08
2.16.840.1.113883.10.20.22.2.60Containmentdraft Goals Section (2.1)2015‑08‑13
2.16.840.1.113883.10.20.22.4.121Containmentdraft Goal Observation (2.1)2015‑08‑13
Uses as NameVersion
2.16.840.1.113883.10.20.22.4.115Containmentdraft External Document Reference (2.1)2014‑06‑09
2.16.840.1.113883.10.20.22.4.119Containmentdraft Author Participation (2.1)2015‑08‑13
2.16.840.1.113883.10.20.22.4.121Containmentdraft Goal Observation (2.1)2015‑08‑13
2.16.840.1.113883.10.20.22.4.122Containmentdraft Entry Reference (2.1)2015‑08‑13
2.16.840.1.113883.10.20.22.4.143Containmentdraft Priority Preference (2.1)2015‑08‑13
RelationshipSpecialization: template 2.16.840.1.113883.10.12.303 CDA Observation (2005‑09‑07)
ref
ad1bbr-
ItemDTCardConfDescriptionLabel
cda:observation
Goaldotstion
@classCode
cs1 … 1FOBSCONFdots0418
 SHALL contain exactly one [1..1] @classCode="OBS" Observation (CodeSystem: HL7ActClass urn:oid:2.16.840.1.113883.5.6) (CONF:1098-30418).
@moodCode
cs1 … 1FGOLCONFdots0419
 SHALL contain exactly one [1..1] @moodCode="GOL" Goal (CodeSystem: ActMood urn:oid:2.16.840.1.113883.5.1001) (CONF:1098-30419).
cda:templateId
II1 … 1MSHALL contain exactly one [1..1] templateId (CONF:1098-8583) such that itCONFdots8583
@root
uid1 … 1F2.16.840.1.113883.10.20.22.4.121CONFdots0512
 SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.121" (CONF:1098-10512).
cda:id
II1 … *SHALL contain at least one [1..*] id (CONF:1098-32332).CONFdots2332
cda:code
CD (extensible)1 … 1SHALL contain exactly one [1..1] code, which SHOULD be selected from CodeSystem LOINC (urn:oid:2.16.840.1.113883.6.1) (CONF:1098-30784).CONFdots0784
@codeSystem
CONF0 … 1F2.16.840.1.113883.6.1
cda:statusCode
CS1 … 1MSHALL contain exactly one [1..1] statusCode (CONF:1098-32333).CONFdots2333
@code
CONF1 … 1Factive
cda:effectiveTime
IVL_TS0 … 1RSHOULD contain zero or one [0..1] effectiveTime (CONF:1098-32335).CONFdots2335
cda:value
0 … 1MAY contain zero or one [0..1] value (CONF:1098-32743).CONFdots2743
cda:author
0 … *

SHOULD contain zero or more [0..*] Author Participation (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.119) (CONF:1098-30995).

If the author is set to the recordTarget (patient), this is a patient goal. If the author is set to a provider, this is a provider goal. If both patient and provider are set as authors, this is a negotiated goal.


Contains 2.16.840.1.113883.10.20.22.4.119 Author Participation (2015‑08‑13)		CONFdots0995
cda:entryRelationship
0 … *The following entryRelationship represents the relationship between a Goal Observation and a Health Concern Act (Goal Observation REFERS TO Health Concern Act). As Health Concern Act is already defined in Health Concerns Section, rather than clone the whole Health Concern Act template, an Entry Reference may be used in entryRelationship to refer the template.
Contains 2.16.840.1.113883.10.20.22.4.122 Entry Reference (2015‑08‑13)		CONFdots0701
where [@typeCode='REFR']
@typeCode
cs1 … 1FREFRCONFdots0702
 SHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:1098-30702).
cda:entryRelationship
0 … *The following entryRelationship represents a planned component of the goal such as Planned Encounter (V2), Planned Observation (V2), Planned Procedure (V2), Planned Medication Activity (V2), Planned Supply (V2), Planned Act (V2) or Planned Immunization Activity. Because these entries are already described in the Interventions Section of the CDA document instance, rather than repeating the full content of the entries, the Entry Reference template may be used to reference the entries.
Contains 2.16.840.1.113883.10.20.22.4.122 Entry Reference (2015‑08‑13)		CONFdots0704
where [@typeCode='COMP']
@typeCode
cs1 … 1FCOMPCONFdots0705
 SHALL contain exactly one [1..1] @typeCode="COMP" Has component (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:1098-30705).
cda:entryRelationship
0 … 1RThe following entryRelationship represents the priority that the patient or a provider puts on the goal.
Contains 2.16.840.1.113883.10.20.22.4.143 Priority Preference (2015‑08‑13)		CONFdots0785
@typeCode
cs1 … 1FREFRCONFdots0786
 SHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:1098-30786).
cda:entryRelationship
0 … *The following entryRelationship represents the relationship between two Goal Observations where the target is a component of the source (Goal Observation HAS COMPONENT Goal Observation). The component goal (target) is a Milestone.
Contains 2.16.840.1.113883.10.20.22.4.121 Goal Observation (2015‑08‑13)		CONFdots1448
@typeCode
cs1 … 1FCOMPCONFdots1449
 SHALL contain exactly one [1..1] @typeCode="COMP" Has component (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:1098-31449).
cda:entryRelationship
0 … *Where a Goal Observation needs to reference another entry already described in the CDA document instance, rather than repeating the full content of the entry, the Entry Reference template may be used to reference this entry.
Contains 2.16.840.1.113883.10.20.22.4.122 Entry Reference (2015‑08‑13)		CONFdots1559
@typeCode
cs1 … 1FREFRCONFdots1560
 SHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:1098-31560).
cda:reference
0 … *Where it is necessary to reference an external clinical document such a Referral document, Discharge Summary document etc., the External Document Reference template can be used to reference this document. However, if this Care Plan document is replacing or appending another Care Plan document in the same set, that relationship is set in the header, using ClinicalDocument/relatedDocument.
Contains 2.16.840.1.113883.10.20.22.4.115 External Document Reference (2014‑06‑09)		CONFdots2754
@typeCode
cs1 … 1FREFRCONFdots2755
 The reference, if present, SHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:1098-32755).