Care Goal

Care Goal represents a defined target or measure to be achieved in the process of patient care, that is, an expected outcome. A typical goal is expressed as a change in status expected at a defined future time. That change can be an observation represented by other QDM categories (diagnostic tests, laboratory tests, symptoms, etc.) scheduled for some time in the future and with a particular value. A goal can be found in the plan of care (care plan), the structure used by all stakeholders, including the patient, to define the management actions for the various conditions, problems, or issues identified for the target of the plan. This structure, through which the goals and care-planning actions and processes can be organized, planned, communicated, and checked for completion, is represented in the QDM categories as a record artifact. A time/date stamp is required. Specifically, a care plan is composed of the elements:

• Problem, which is managed by other QDM standard categories (condition/diagnosis/ problem) and their related data elements.
• Procedure, which is managed by other standard categories and their related data elements.
  • Note that procedures are a continuum of interventions ranging from actions patients can do for themselves to those that can be performed by others (caregivers or clinical professionals), including detailed complex surgical procedures requiring highly trained physicians, nurses, and state-of-the-art facilities.
• Goal, which is what is expected to happen.
• Outcome, which is what happened. An outcome can be shown by other QDM standard categories and their related data elements such as "Procedure, Performed", "Intervention, Performed", "Assessment, Performed", "Physical Exam, Performed".