CareTeam — Care team

The multidisciplinary team around a patient: primary care physician, specialists, caregivers, family carers, even the patient themselves. Models roles, time windows, and attached organisations.

Purpose of the resource

CareTeam represents all the people and organisations who plan to participate in the coordination and delivery of care for a specific patient, a group, or even an event before the subject is identified (e.g., the emergency response team of a department). It structures the multidisciplinary team: primary care physician, consulting specialists, nurses, physiotherapists, family caregivers, case manager, care coordinator, the patient themselves.

Referenced from CarePlan, Encounter, Condition and Goal, CareTeam is the horizontal coordination element that ties every actor to the patient journey. The US Core CareTeam profile is mandatory for ONC EHR certification: every patient must be able to list their team.

Key fields

Statuses

ValueSet CareTeamStatus, Required binding:

JSON example

Multidisciplinary team assembled for a patient's diabetes follow-up: general practitioner, psychologist, nurse, family caregiver.

{
  "resourceType": "CareTeam",
  "id": "example",
  "identifier": [{
    "system": "http://example.org/identifiers/careteam",
    "value": "CT-2026-187"
  }],
  "status": "active",
  "category": [{
    "coding": [{
      "system": "http://loinc.org",
      "code": "LA28865-6",
      "display": "Longitudinal care-coordination focused care team"
    }]
  }],
  "name": "Multidisciplinary team — Peter Chalmers",
  "subject": { "reference": "Patient/example", "display": "Peter Chalmers" },
  "period": {
    "start": "2026-05-14"
  },
  "participant": [{
    "role": {
      "coding": [{
        "system": "http://snomed.info/sct",
        "code": "446050000",
        "display": "Primary care physician"
      }]
    },
    "member": { "reference": "Practitioner/example", "display": "Dr Adam Careful" },
    "onBehalfOf": { "reference": "Organization/hosp01" }
  }, {
    "role": {
      "coding": [{
        "system": "http://snomed.info/sct",
        "code": "59944000",
        "display": "Psychologist"
      }]
    },
    "member": { "reference": "Practitioner/dr-elias", "display": "Dr Elias Sammer" }
  }, {
    "role": {
      "coding": [{
        "system": "http://snomed.info/sct",
        "code": "224535009",
        "display": "Registered nurse"
      }]
    },
    "member": { "reference": "Practitioner/nurse-lopez", "display": "Lopez, RN" }
  }, {
    "role": {
      "coding": [{
        "system": "http://snomed.info/sct",
        "code": "133932002",
        "display": "Caregiver"
      }]
    },
    "member": { "reference": "RelatedPerson/peter-spouse", "display": "Ms. Chalmers (spouse)" }
  }],
  "reason": [{
    "concept": {
      "coding": [{
        "system": "http://snomed.info/sct",
        "code": "44054006",
        "display": "Diabetes mellitus type 2"
      }]
    }
  }],
  "managingOrganization": [{ "reference": "Organization/hosp01" }],
  "telecom": [{
    "system": "phone",
    "value": "+33 1 23 45 67 89",
    "use": "work"
  }]
}

Worth pointing out in this example:

• Four participant[] entries with precise SNOMED CT roles (Primary care physician, Psychologist, Registered nurse, Caregiver).
• The fourth participant is a RelatedPerson — the caregiver spouse: CareTeam is not limited to professionals.
• onBehalfOf indicates that Dr Careful operates on behalf of the hospital, relevant for billing and legal liability.
• reason codes the pathology motivating team setup (type 2 diabetes).
• The team is active from 14 May 2026, with no end date (longitudinal follow-up).

Common pitfalls

• Empty CareTeam — a CareTeam with no participant has no business value. No FHIR constraint, but semantically empty.
• Patient not listed — the US Core CareTeam profile recommends including the patient as a member (role "Patient") to materialise shared decision making.
• Confusion participant.member Practitioner / PractitionerRole — prefer PractitionerRole when a single Practitioner has multiple roles across multiple Organizations. Direct Practitioner for simple roles.
• Several active CareTeams on the same patient with no coordination — common in large hospitals without a Master CareTeam. Avoid via clear categorisation (category=longitudinal vs encounter).
• Missing onBehalfOf for a freelance Practitioner — without onBehalfOf, one cannot distinguish a personal intervention from one on behalf of an organisation.
• Member periods inconsistent with period — a participant.coverage[x] that exceeds the team's global period is suspicious (but not FHIR-invalid).
• Member removal by deletion — don't delete the member from the array: close their coverage[x] instead, to preserve audit trail.

Related resources

• CarePlan — care plan(s) referencing the team.
• Practitioner, PractitionerRole — healthcare professional members.
• RelatedPerson — caregivers, family, trusted third parties.
• Patient — may appear as a member of their own team.
• Organization — managing or represented organisation.
• EpisodeOfCare — episode of care that may reference the CareTeam.
• Encounter, Condition — reference the team to link the episode with its actors.

See also: the FHIR R5 index.