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

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

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<CarePlan xmlns="http://hl7.org/fhir">
  <id value="example-kpr-careplan"/>
  <meta>
    <profile
             value="https://kommune.conteir.no/StructureDefinition/kommune-careplan"/>
  </meta>
  <language value="en"/>
  <text>
    <status value="generated"/>
    <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>
</div></blockquote><p><b>reference</b>: <a href="ServiceRequest-example-kpr-service.html">ServiceRequest Helsetjenester i hjemmet</a></p></blockquote></div>
  </text>
  <status value="active"/>
  <intent value="plan"/>
  <title value="Self-care and functional follow-up at home"/>
  <description
               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."/>
  <subject>🔗 
    <reference value="Patient/example-patient"/>
  </subject>
  <encounter>🔗 
    <reference value="Encounter/example-kpr-followup-encounter"/>
  </encounter>
  <period>
    <start value="2026-08-18"/>
  </period>
  <created value="2026-08-17T11:30:00+02:00"/>
  <author>🔗 
    <reference value="PractitionerRole/example-practitionerrole"/>
  </author>
  <supportingInfo>🔗 
    <reference value="Observation/example-kpr-function"/>
  </supportingInfo>
  <supportingInfo>🔗 
    <reference value="Observation/example-kpr-mobility"/>
  </supportingInfo>
  <supportingInfo>🔗 
    <reference value="Observation/example-kpr-vision"/>
  </supportingInfo>
  <supportingInfo>🔗 
    <reference value="Observation/example-kpr-hearing"/>
  </supportingInfo>
  <goal>🔗 
    <reference value="Goal/example-kpr-goal"/>
  </goal>
  <activity>
    <outcomeReference>🔗 
      <reference value="Encounter/example-kpr-followup-encounter"/>
    </outcomeReference>
    <outcomeReference>🔗 
      <reference value="Observation/example-kpr-followup"/>
    </outcomeReference>
    <progress>
      <time value="2026-08-31T11:30:00+02:00"/>
      <text
            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."/>
    </progress>
    <reference>🔗 
      <reference value="ServiceRequest/example-kpr-service"/>
    </reference>
  </activity>
</CarePlan>