Implement US Core CareTeam and Goal resources for a patient with chronic conditions

In-depth guide

Steps

1. 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
2. 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
3. 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)
4. 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)
5. 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
6. 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