Goal A goal refers to an objective to be achieved as a consequence of health care interventions applied to an individual. Goals are set in many areas of the health care system, and include educational, behavior modification, and clinical goals such as reduced discomfort, improved circulation. Goals are documented by a variety of health care professionals including physicians, nurses, and respiratory and other therapists. Goals are defined during patient visits and they may span one or multiple visits, encounters, or episodes of care.
Problems can be short or long term in nature, chronic or acute, and have a status.
In a longitudinal record, all problems may be of importance in the overall long term care of an individual, and may undergo changes in status repeatedly. Problems are identified during patient visits, and may span multiple visits, encounters, or episodes of care. Role A role refers to the function or responsibility assumed by a person in the context of a health care event. Role information documents a person's association with an identified healthcare activity. Examples include primary care provider, transcriptionist, reviewer, and consulting physician.