HL7 Norge
FHIR Implementation Guide for the Norwegian Municipal Sector
Shared starting point for understanding and consistent use of FHIR in municipal health and care services.
Norwegian

FHIR Implementation Guide for the Norwegian Municipal Sector
0.3.0 - Norway flag

FHIR Implementation Guide for the Norwegian Municipal Sector - Local Development build (v0.3.0) built by the FHIR (HL7® FHIR® Standard) Build Tools. See the Directory of published versions

: Municipal journey: plan with assessment basis and follow-up

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@prefix fhir: <http://hl7.org/fhir/> .
@prefix owl: <http://www.w3.org/2002/07/owl#> .
@prefix rdfs: <http://www.w3.org/2000/01/rdf-schema#> .
@prefix xsd: <http://www.w3.org/2001/XMLSchema#> .

# - resource -------------------------------------------------------------------

<http://hl7.org/fhir/CarePlan/example-kpr-careplan> a fhir:CarePlan ;
  fhir:nodeRole fhir:treeRoot ;
  fhir:Resource.id [ fhir:value "example-kpr-careplan"] ;
  fhir:Resource.meta [
     fhir:Meta.profile [
       fhir:value "https://kommune.conteir.no/StructureDefinition/kommune-careplan" ;
       fhir:index -1 ;
       fhir:link <https://kommune.conteir.no/StructureDefinition/kommune-careplan>
     ]
  ] ;
  fhir:Resource.language [ fhir:value "en"] ;
  fhir:DomainResource.text [
     fhir:Narrative.status [ fhir:value "generated" ] ;
     fhir:Narrative.div "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p class=\"res-header-id\"><b>Generated Narrative: CarePlan example-kpr-careplan</b></p><a name=\"example-kpr-careplan\"> </a><a name=\"hcexample-kpr-careplan\"> </a><div style=\"display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%\"><p style=\"margin-bottom: 0px\"/><p style=\"margin-bottom: 0px\">Profile: <a href=\"StructureDefinition-kommune-careplan.html\">no-kommune-CarePlan</a></p></div><p><b>status</b>: Active</p><p><b>intent</b>: Plan</p><p><b>title</b>: Self-care and functional follow-up at home</p><p><b>description</b>: The plan is based on the 17 August assessment and updated after the 31 August home visit. Changes to services require a separate assessment and are not inferred automatically from scores.</p><p><b>subject</b>: <a href=\"Patient-example-patient.html\">Kari Hansen  Female, DoB: 1948-09-12 ( urn:oid:2.16.578.1.12.4.1.4.1#Foedselsnummer#12094812345)</a></p><p><b>encounter</b>: <a href=\"Encounter-example-kpr-followup-encounter.html\">Encounter: status = finished; class = home health (ActCode#HH); type = ; serviceType = Helsetjenester i hjemmet; period = 2026-08-31 09:30:00+0200 --&gt; 2026-08-31 10:30:00+0200</a></p><p><b>period</b>: 2026-08-18 --&gt; (ongoing)</p><p><b>created</b>: 2026-08-17 11:30:00+0200</p><p><b>author</b>: <a href=\"PractitionerRole-example-practitionerrole.html\">PractitionerRole</a></p><p><b>supportingInfo</b>: </p><ul><li><a href=\"Observation-example-kpr-function.html\">Observation Personlig hygiene</a></li><li><a href=\"Observation-example-kpr-mobility.html\">Observation Bevege seg innendørs</a></li><li><a href=\"Observation-example-kpr-vision.html\">Observation Syn</a></li><li><a href=\"Observation-example-kpr-hearing.html\">Observation Hørsel</a></li></ul><p><b>goal</b>: <a href=\"Goal-example-kpr-goal.html\">Goal: lifecycleStatus = active; description = ; start[x] = 2026-08-18</a></p><blockquote><p><b>activity</b></p><p><b>outcomeReference</b>: </p><ul><li><a href=\"Encounter-example-kpr-followup-encounter.html\">Encounter: status = finished; class = home health (ActCode#HH); type = ; serviceType = Helsetjenester i hjemmet; period = 2026-08-31 09:30:00+0200 --&gt; 2026-08-31 10:30:00+0200</a></li><li><a href=\"Observation-example-kpr-followup.html\">Observation Personlig hygiene</a></li></ul><p><b>progress</b>: @2026-08-31 11:30:00+0200</p><blockquote><div><p>Reassessment shows a change from score 3 to 2 for personal hygiene. Review further assistance with Kari. The first assessment and original request basis are retained.</p>\n</div></blockquote><p><b>reference</b>: <a href=\"ServiceRequest-example-kpr-service.html\">ServiceRequest Helsetjenester i hjemmet</a></p></blockquote></div>"
  ] ;
  fhir:CarePlan.status [ fhir:value "active"] ;
  fhir:CarePlan.intent [ fhir:value "plan"] ;
  fhir:CarePlan.title [ fhir:value "Self-care and functional follow-up at home"] ;
  fhir:CarePlan.description [ fhir:value "The plan is based on the 17 August assessment and updated after the 31 August home visit. Changes to services require a separate assessment and are not inferred automatically from scores."] ;
  fhir:CarePlan.subject [
     fhir:link <http://hl7.org/fhir/Patient/example-patient> ;
     fhir:Reference.reference [ fhir:value "Patient/example-patient" ]
  ] ;
  fhir:CarePlan.encounter [
     fhir:link <http://hl7.org/fhir/Encounter/example-kpr-followup-encounter> ;
     fhir:Reference.reference [ fhir:value "Encounter/example-kpr-followup-encounter" ]
  ] ;
  fhir:CarePlan.period [
     fhir:Period.start [ fhir:value "2026-08-18"^^xsd:date ]
  ] ;
  fhir:CarePlan.created [ fhir:value "2026-08-17T11:30:00+02:00"^^xsd:dateTime] ;
  fhir:CarePlan.author [
     fhir:link <http://hl7.org/fhir/PractitionerRole/example-practitionerrole> ;
     fhir:Reference.reference [ fhir:value "PractitionerRole/example-practitionerrole" ]
  ] ;
  fhir:CarePlan.supportingInfo [
     fhir:index -1 ;
     fhir:link <http://hl7.org/fhir/Observation/example-kpr-function> ;
     fhir:Reference.reference [ fhir:value "Observation/example-kpr-function" ]
  ], [
     fhir:index -1 ;
     fhir:link <http://hl7.org/fhir/Observation/example-kpr-mobility> ;
     fhir:Reference.reference [ fhir:value "Observation/example-kpr-mobility" ]
  ], [
     fhir:index -1 ;
     fhir:link <http://hl7.org/fhir/Observation/example-kpr-vision> ;
     fhir:Reference.reference [ fhir:value "Observation/example-kpr-vision" ]
  ], [
     fhir:index -1 ;
     fhir:link <http://hl7.org/fhir/Observation/example-kpr-hearing> ;
     fhir:Reference.reference [ fhir:value "Observation/example-kpr-hearing" ]
  ] ;
  fhir:CarePlan.goal [
     fhir:index -1 ;
     fhir:link <http://hl7.org/fhir/Goal/example-kpr-goal> ;
     fhir:Reference.reference [ fhir:value "Goal/example-kpr-goal" ]
  ] ;
  fhir:CarePlan.activity [
     fhir:index -1 ;
     fhir:CarePlan.activity.outcomeReference [
       fhir:index -1 ;
       fhir:link <http://hl7.org/fhir/Encounter/example-kpr-followup-encounter> ;
       fhir:Reference.reference [ fhir:value "Encounter/example-kpr-followup-encounter" ]
     ], [
       fhir:index -1 ;
       fhir:link <http://hl7.org/fhir/Observation/example-kpr-followup> ;
       fhir:Reference.reference [ fhir:value "Observation/example-kpr-followup" ]
     ] ;
     fhir:CarePlan.activity.progress [
       fhir:index -1 ;
       fhir:Annotation.time [ fhir:value "2026-08-31T11:30:00+02:00"^^xsd:dateTime ] ;
       fhir:Annotation.text [ fhir:value "Reassessment shows a change from score 3 to 2 for personal hygiene. Review further assistance with Kari. The first assessment and original request basis are retained." ]
     ] ;
     fhir:CarePlan.activity.reference [
       fhir:link <http://hl7.org/fhir/ServiceRequest/example-kpr-service> ;
       fhir:Reference.reference [ fhir:value "ServiceRequest/example-kpr-service" ]
     ]
  ] .

<http://hl7.org/fhir/Patient/example-patient> a fhir:Patient .

<http://hl7.org/fhir/Encounter/example-kpr-followup-encounter> a fhir:Encounter .

<http://hl7.org/fhir/PractitionerRole/example-practitionerrole> a fhir:PractitionerRole .

<http://hl7.org/fhir/Observation/example-kpr-function> a fhir:Observation .

<http://hl7.org/fhir/Observation/example-kpr-mobility> a fhir:Observation .

<http://hl7.org/fhir/Observation/example-kpr-vision> a fhir:Observation .

<http://hl7.org/fhir/Observation/example-kpr-hearing> a fhir:Observation .

<http://hl7.org/fhir/Goal/example-kpr-goal> a fhir:Goal .

<http://hl7.org/fhir/Observation/example-kpr-followup> a fhir:Observation .

<http://hl7.org/fhir/ServiceRequest/example-kpr-service> a fhir:ServiceRequest .

# - ontology header ------------------------------------------------------------

<http://hl7.org/fhir/CarePlan/example-kpr-careplan.ttl> a owl:Ontology ;
  owl:imports fhir:fhir.ttl ;
  owl:versionIRI <http://build.fhir.org/CarePlan/example-kpr-careplan.ttl> .