Pflegeziel
Pflegeziele werden als Goal angegeben. Unter description
können die Codesysteme für pflegerische Klassifikationen für pflegerische Ziele genutzt werden.
Goal | I | Goal | There are no (further) constraints on this element Element IdGoal Describes the intended objective(s) for a patient, group or organization DefinitionDescribes 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.
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identifier | 0..* | Identifier | There are no (further) constraints on this element Element IdGoal.identifier External Ids for this goal DefinitionBusiness 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. Allows identification of the goal as it is known by various participating systems and in a way that remains consistent across servers. This is a business identifier, not a resource identifier (see discussion). 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.
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lifecycleStatus | Σ ?! | 1..1 | codeBinding | There are no (further) constraints on this element Element IdGoal.lifecycleStatus proposed | planned | accepted | active | on-hold | completed | cancelled | entered-in-error | rejected DefinitionThe state of the goal throughout its lifecycle. Allows knowing whether goal needs to be further tracked. This element is labeled as a modifier because the lifecycleStatus contains codes that mark the resource as not currently valid. Codes that reflect the current state of a goal and whether the goal is still being targeted. GoalLifecycleStatus (required)Constraints
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achievementStatus | Σ | 0..1 | CodeableConceptBinding | There are no (further) constraints on this element Element IdGoal.achievementStatus in-progress | improving | worsening | no-change | achieved | sustaining | not-achieved | no-progress | not-attainable DefinitionDescribes the progression, or lack thereof, towards the goal against the target. Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination. Indicates the progression, or lack thereof, towards the goal against the target. GoalAchievementStatus (preferred)Constraints
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category | Σ | 0..* | CodeableConcept | There are no (further) constraints on this element Element IdGoal.category E.g. Treatment, dietary, behavioral, etc. DefinitionIndicates a category the goal falls within. Allows goals to be filtered and sorted. Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination. Codes for grouping and sorting goals. GoalCategory (example)Constraints
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coding | Σ | 0..* | Coding | There are no (further) constraints on this element Element IdGoal.category.coding Code defined by a terminology system DefinitionA reference to a code defined by a terminology system. Allows for alternative encodings within a code system, and translations to other code systems. Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true.
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system | Σ | 0..1 | uriFixed Value | Element IdGoal.category.coding.system Identity of the terminology system DefinitionThe identification of the code system that defines the meaning of the symbol in the code. Need to be unambiguous about the source of the definition of the symbol. The URI may be an OID (urn:oid:...) or a UUID (urn:uuid:...). OIDs and UUIDs SHALL be references to the HL7 OID registry. Otherwise, the URI should come from HL7's list of FHIR defined special URIs or it should reference to some definition that establishes the system clearly and unambiguously.
http://terminology.hl7.org/CodeSystem/goal-category
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version | Σ | 0..1 | string | There are no (further) constraints on this element Element IdGoal.category.coding.version Version of the system - if relevant DefinitionThe version of the code system which was used when choosing this code. Note that a well-maintained code system does not need the version reported, because the meaning of codes is consistent across versions. However this cannot consistently be assured, and when the meaning is not guaranteed to be consistent, the version SHOULD be exchanged. Where the terminology does not clearly define what string should be used to identify code system versions, the recommendation is to use the date (expressed in FHIR date format) on which that version was officially published as the version date.
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code | Σ | 0..1 | codeFixed Value | Element IdGoal.category.coding.code Symbol in syntax defined by the system DefinitionA symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination). Need to refer to a particular code in the system. Note that FHIR strings SHALL NOT exceed 1MB in size
nursing
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display | Σ | 0..1 | string | There are no (further) constraints on this element Element IdGoal.category.coding.display Representation defined by the system DefinitionA representation of the meaning of the code in the system, following the rules of the system. Need to be able to carry a human-readable meaning of the code for readers that do not know the system. Note that FHIR strings SHALL NOT exceed 1MB in size
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userSelected | Σ | 0..1 | boolean | There are no (further) constraints on this element Element IdGoal.category.coding.userSelected If this coding was chosen directly by the user DefinitionIndicates that this coding was chosen by a user directly - e.g. off a pick list of available items (codes or displays). This has been identified as a clinical safety criterium - that this exact system/code pair was chosen explicitly, rather than inferred by the system based on some rules or language processing. Amongst a set of alternatives, a directly chosen code is the most appropriate starting point for new translations. There is some ambiguity about what exactly 'directly chosen' implies, and trading partner agreement may be needed to clarify the use of this element and its consequences more completely.
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text | Σ | 0..1 | string | There are no (further) constraints on this element Element IdGoal.category.text Plain text representation of the concept DefinitionA human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user. The codes from the terminologies do not always capture the correct meaning with all the nuances of the human using them, or sometimes there is no appropriate code at all. In these cases, the text is used to capture the full meaning of the source. Very often the text is the same as a displayName of one of the codings.
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priority | Σ | 0..1 | CodeableConceptBinding | There are no (further) constraints on this element Element IdGoal.priority high-priority | medium-priority | low-priority DefinitionIdentifies the mutually agreed level of importance associated with reaching/sustaining the goal. Used for sorting and presenting goals. 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". The level of importance associated with a goal. GoalPriority (preferred)Constraints
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description | S Σ | 1..1 | CodeableConcept | There are no (further) constraints on this element Element IdGoal.description Code or text describing goal DefinitionHuman-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". Without a description of what's trying to be achieved, element has no purpose. If no code is available, use CodeableConcept.text. 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. SNOMEDCTClinicalFindings (example)Constraints
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coding | Σ | 0..* | Coding | Element IdGoal.description.coding Code defined by a terminology system DefinitionA reference to a code defined by a terminology system. Allows for alternative encodings within a code system, and translations to other code systems. Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true.
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text | Σ | 0..1 | string | There are no (further) constraints on this element Element IdGoal.description.text Plain text representation of the concept DefinitionA human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user. The codes from the terminologies do not always capture the correct meaning with all the nuances of the human using them, or sometimes there is no appropriate code at all. In these cases, the text is used to capture the full meaning of the source. Very often the text is the same as a displayName of one of the codings.
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subject | Σ I | 1..1 | Reference(Patient | Group | Organization) | There are no (further) constraints on this element Element IdGoal.subject Who this goal is intended for DefinitionIdentifies the patient, group or organization for whom the goal is being established. Subject is optional to support annonymized reporting. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository. Reference(Patient | Group | Organization) Constraints
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start[x] | Σ | 0..1 | There are no (further) constraints on this element Element IdGoal.start[x] When goal pursuit begins DefinitionThe date or event after which the goal should begin being pursued. Goals can be established prior to there being an intention to start pursuing them; e.g. Goals for post-surgical recovery established prior to surgery. Codes describing events that can trigger the initiation of a goal. GoalStartEvent (example)Constraints
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startDate | date | There are no (further) constraints on this element Data Type | ||
startCodeableConcept | CodeableConcept | There are no (further) constraints on this element Data Type | ||
target | I | 0..* | BackboneElement | There are no (further) constraints on this element Element IdGoal.target Target outcome for the goal DefinitionIndicates what should be done by when. Allows the progress of the goal to be monitored against an observation or due date. Target is 0..* to support Observations with multiple components, such as blood pressure goals with both a systolic and diastolic target. When multiple targets are present for a single goal instance, all targets must be met for the overall goal to be met.
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measure | Σ I | 0..1 | CodeableConcept | There are no (further) constraints on this element Element IdGoal.target.measure The parameter whose value is being tracked DefinitionThe parameter whose value is being tracked, e.g. body weight, blood pressure, or hemoglobin A1c level. Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination. Codes to identify the value being tracked, e.g. body weight, blood pressure, or hemoglobin A1c level. LOINCCodes (example)Constraints
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detail[x] | Σ I | 0..1 | There are no (further) constraints on this element Element IdGoal.target.detail[x] The target value to be achieved DefinitionThe 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. Codes to identify the target value of the focus to be achieved to signify the fulfillment of the goal. (unbound) (example)Constraints
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detailQuantity | Quantity | There are no (further) constraints on this element Data Type | ||
detailRange | Range | There are no (further) constraints on this element Data Type | ||
detailCodeableConcept | CodeableConcept | There are no (further) constraints on this element Data Type | ||
detailString | string | There are no (further) constraints on this element Data Type | ||
detailBoolean | boolean | There are no (further) constraints on this element Data Type | ||
detailInteger | integer | There are no (further) constraints on this element Data Type | ||
detailRatio | Ratio | There are no (further) constraints on this element Data Type | ||
due[x] | Σ | 0..1 | There are no (further) constraints on this element Element IdGoal.target.due[x] Reach goal on or before DefinitionIndicates either the date or the duration after start by which the goal should be met. Identifies when the goal should be evaluated.
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dueDate | date | There are no (further) constraints on this element Data Type | ||
dueDuration | Duration | There are no (further) constraints on this element Data Type | ||
statusDate | Σ | 0..1 | date | There are no (further) constraints on this element Element IdGoal.statusDate When goal status took effect DefinitionIdentifies when the current status. I.e. When initially created, when achieved, when cancelled, etc. To see the date for past statuses, query history.
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statusReason | 0..1 | string | There are no (further) constraints on this element Element IdGoal.statusReason Reason for current status DefinitionCaptures 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.
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expressedBy | Σ I | 0..1 | Reference(Patient | Practitioner | PractitionerRole | RelatedPerson) | There are no (further) constraints on this element Element IdGoal.expressedBy Who's responsible for creating Goal? DefinitionIndicates 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.). Reference(Patient | Practitioner | PractitionerRole | RelatedPerson) Constraints
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addresses | S I | 0..* | Reference(Condition | Observation | RiskAssessment | GeNSNursingProblem | GeNSNursingAssessment | GeNSRiskAssessment) | Element IdGoal.addresses Issues addressed by this goal DefinitionThe identified conditions and other health record elements that are intended to be addressed by the goal. Allows specific goals to explicitly linked to the concerns they're dealing with - makes the goal more understandable. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository. Reference(Condition | Observation | RiskAssessment | GeNSNursingProblem | GeNSNursingAssessment | GeNSRiskAssessment) Constraints
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note | 0..* | Annotation | There are no (further) constraints on this element Element IdGoal.note Comments about the goal DefinitionAny comments related to the goal. There's a need to capture information about the goal that doesn't actually describe the goal. May be used for progress notes, concerns or other related information that doesn't actually describe the goal itself.
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outcomeCode | S | 0..* | CodeableConcept | There are no (further) constraints on this element Element IdGoal.outcomeCode What result was achieved regarding the goal? DefinitionIdentifies the change (or lack of change) at the point when the status of the goal is assessed. Outcome tracking is a key aspect of care planning. Note that this should not duplicate the goal status. 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". SNOMEDCTClinicalFindings (example)Constraints
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outcomeReference | I | 0..* | Reference(Observation) | There are no (further) constraints on this element Element IdGoal.outcomeReference Observation that resulted from goal DefinitionDetails of what's changed (or not changed). Outcome tracking is a key aspect of care planning. 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.
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