Within an encounter’s Plan section, there is an optional Goals encounter section that can be utilized. This section can be used to document the patient’s desired outcomes or goals related to their care, such as improving mobility, managing pain, or achieving specific health milestones.
Goals can also be documented within the Smart Plan encounter section.
Any goals that already exist as documented on the chart, appear in the Goals encounter section and/or within the Goals section of Smart Plan encounter section.
Goals Right Side Quick List Method
A banner or bookmark icon is located on the right side of the Goals encounter section. This can be clicked to expand open to utilize the right side quick list functionality for the Goals section.
Add Goal
From the Goals section, using the right side Quick list method, a search is available to search for a specific preconfigured goal within the library you are set to, or click the + icon can be used to document a Goal to the encounter visit.
Using the + icon will display an Add Goal pop-up window to enter in details of the desired goal.
- Goal: use the autocomplete to select a specific observation that the system offers and stores. This field does not allow freetext. For more information on where system wide observations are configured and managed, please refer to Observation Codes Editor.
- Next Date: This field is optional, but can designate a specific date wanting this goal to be obtained by.
- Target: This field is optional, but can free text the Target of this goal to have.
In the below example, a goal for the patient is to reduce their LDL Cholesterol labs to be less than 165 by August 21, 2025.
Once saved, the goal displays in the Goal encounter section (and/or in smart plan section) in a bulleted list with the goal, target indicated, and the ‘by’ date (next date).
If the chart has had prior results/values documented for the specific observation, the Goals section will list the last 5 most recent values/results for that discrete observation, along with the date of that prior value. This helps visibility see trending for that goal.
Quick List - Library
The Goals right side quick list method allows you to select Goals (observations) that are preconfigured on the Library chart you are currently set to on the encounter or are set to within this specific Goals section.
The encounter in its entirety can be set to a specific chosen Library, or the Goals encounter section can be set to a specific library. If the chosen library has Goals preconfigured to it, those goals will display as Quick List selections. Please refer to the Libraries guide for more detailed information.
Blue icon
A checkmark blue circle icon next to an item on the Goals right side quick list method signifies that goal selection has been applied to the encounter section.
Options
A goal has option buttons. One can edit a goal, delete a goal, rearrange the display order of goals in that section, or generate a task about/related to that goal.
Goals cannot be marked as historical, nor as achieved. Goals are meant to stay with the chart as a lifetime with a trending ‘most recent last 5’ view. Currently, there is no reporting around Goals in a system.
Symptoms/Diagnosis Encounter Section
Goals are also visible in the Symptoms/Diagnosis encounter section and goals can be managed there also. When/if a goal is documented, it displays in Smart Plan encounter section, Goals encounter section, and Symptoms/Diagnosis encounter section.
Encounter Stored Document
The Goals encounter section does become part of the encounter visit note document once closed and archived.
Visit Summary
If the encounter is configured to generate a Patient Clinical Visit Summary upon close & archive, the goals encounter section contents will be included in that Patient Clinical Visit Summary document.
The Clinical/Visit Summary is a standard additional view that is generated on encounters upon close & archive. This additional view for the Clinical (Visit) Summary is configured in the Encounter Exams editor.
The Patient Clinical Visit Summary has been updated to make it more uniform, compact, and easier to read as a handout given to the patient (or shared to the portal) on the conclusion of their visit. The updated Visit Summary uses 3 main layouts of: Clinical Summary, Vitals, & Vitals_list to populate the contents and includes the Goals encounter section.