Short term Long Term Condition Goal Dance at
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Short term Long Term Condition Goal Dance at daughter’s wedding Adequate Transportation to work Goal Dancing lessons Have a working car Goal Walk 40 feet Have fuel Target Measure Sit on side of bed Have a drivers license Goal Attributes: - short/long term goal - Time based / due date / - soft dates (after x happens, before x) - Target Measure / Sub Goal/interim goals, meta goals, - Primary Issues/Secondary Issues/Contributing Issues/Factors… - Prioritized and who’s priorities - Sequential relationship of sub goals - Protective Factors – how they fit into goals? Care plan, - Are they actions/interventions? - Goals - Therapeutic -. . - Lifestyle. . - SMART – attributes. - What is coded? - What is narrative? - Must be associated with conditions/problems… - Lifecycle of goals – Stephen will on this and send for review. - Conceptual /Logical model – - Compositional and cross compositional
Use cases – how are goals used in: • SDOH • Nursing Care • In patient • Out patient/community… • Physical Therapy • http: //hl 7. org/fhir/uv/cpg/examples. html#goal-index • Need to accommodate the subtleties:
Protective Factors • Nursing approach – goals… looks at the positive and negative influencers… • Goal to • Maintain/obtain positive influencers/protective factors/strengths • correct/change negative influencers/risks
Next Steps • Define a set of use cases describing different applications of goals – All- be thinking of these…write them up • Get a page put together with all the resources we are looking at for this goals discussion. Laura/Stephen • Add more time on the Care Plan weds calls for more discussion - Laura • Gather links and documents related to this topic to be added to/linked to the page above – ALL • Address how Goals work in FHIR • Conceptual and Logical models to be included /enhanced in CP DAM 2. 0 • https: //jira. hl 7. org/browse/FHIR-28546. • http: //hl 7. org/fhir/uv/cpg/2019 Sep/ • http: //hl 7. org/fhir/uv/cpg/examples. html#goal-index
Strive for: • Goals in positive sense, not negation • Goals can be expressed by the presence of a optimal state or the absence of a suboptimal state • Goals as a desired state. . Qualitative Goal Quantitative Goal Strengths/ Protective Factors Need to include: • Multiple authors • Acceptance. . Barriers Preferences (positive/ne gative) Meeting goals sequentially or concurrently
