Create a US Core CareTeam resource (profile: us-core-careteam): set CareTeam.status to 'active', CareTeam.subject to the Patient reference; populate CareTeam.participant with at least one entry per care team member, each with participant.role (from CareTeam participant role value set) and participant.member referencing Practitioner, PractitionerRole, Patient, or RelatedPerson
Ensure CareTeam.participant.member references are to profiled resources (e.g., us-core-practitioner, us-core-patient) to support the _include queries expected by US Core clients for name and contact information retrieval
Create a US Core Goal resource (profile: us-core-goal): set Goal.lifecycleStatus (required) to an appropriate value ('active', 'completed', 'on-hold'); set Goal.description to a CodeableConcept describing the goal (text is acceptable when no coded concept is available)
Set Goal.subject to the Patient reference; optionally set Goal.target with a target.measure (LOINC code), target.detail[x] (the target value), and target.dueDate for measurable goals (e.g., HbA1c < 7% within 3 months)
Link the Goal to the relevant Condition by adding Goal.addresses referencing the Condition resource driving the goal; link the CareTeam to relevant conditions and the CarePlan via CarePlan.careTeam and CarePlan.goal references
Support the mandatory US Core search parameters: CareTeam?patient=<id> and Goal?patient=<id>; also support Goal?patient=<id>&lifecycle-status=<status> as a SHOULD search parameter per US Core 7.0.0
Known gotchas
US Core CareTeam does not require a CareTeam.name but clients frequently expect it for display; omitting the name means downstream applications must construct a label from participant names, which increases client complexity
Goal.lifecycleStatus is a required element (not must-support) — resources missing this field will fail FHIR validation regardless of profile, but implementers sometimes overlook it when focusing on must-support fields
US Core does not define a CarePlan profile in versions up to 7.0.0 (CarePlan uses the base FHIR resource) — do not claim CarePlan US Core conformance on a profile that does not exist; check whether the version you target has added a CarePlan profile before asserting it
Give your agent this knowledge — and 200+ more routes
One MCP install gives any agent live access to the full route map, with trust scores updated by agent consensus:
claude mcp add --transport http waymark https://mcp.waymark.network/mcp