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.
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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

: Example municipal follow-up plan

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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-careplan> a fhir:CarePlan ;
  fhir:nodeRole fhir:treeRoot ;
  fhir:Resource.id [ fhir:value "example-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-careplan</b></p><a name=\"example-careplan\"> </a><a name=\"hcexample-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>category</b>: <span title=\"Codes:\">Municipal follow-up</span></p><p><b>title</b>: Follow-up plan after discharge - Grünerløkka district</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>period</b>: 2026-01-13 --&gt; 2026-03-31</p><p><b>author</b>: <a href=\"PractitionerRole-example-practitionerrole.html\">PractitionerRole</a></p><p><b>careTeam</b>: <a href=\"CareTeam-example-careteam.html\">CareTeam Multidisciplinary follow-up team, Grünerløkka district</a></p><p><b>addresses</b>: <a href=\"Condition-example-health-concern.html\">Health concern after hip fracture</a></p><p><b>supportingInfo</b>: </p><ul><li><a href=\"Condition-example-health-concern.html\">Health concern after hip fracture</a></li><li><a href=\"Observation-example-observation.html\">Observation </a></li><li><a href=\"DocumentReference-example-documentreference.html\">DocumentReference: status = current; type = Journalnotat; date = 2026-01-12 09:00:00+0100; description = Decision on home nursing and practical assistance after discharge</a></li><li><a href=\"Goal-example-goal.html\">Goal: lifecycleStatus = active; description = ; start[x] = 2026-01-20</a></li></ul><p><b>goal</b>: <a href=\"Goal-example-goal.html\">Goal: lifecycleStatus = active; description = ; start[x] = 2026-01-20</a></p><blockquote><p><b>activity</b></p><p><b>outcomeReference</b>: </p><ul><li><a href=\"Encounter-example-encounter.html\">Encounter: status = finished; class = ambulatory (ActCode#AMB); type = ; serviceType = ; period = 2026-01-15 10:00:00+0100 --&gt; 2026-01-15 10:45:00+0100</a></li><li><a href=\"Encounter-example-encounter-followup.html\">Encounter: status = finished; class = virtual (ActCode#VR); type = ; serviceType = ; period = 2026-01-22 11:00:00+0100 --&gt; 2026-01-22 11:20:00+0100</a></li><li><a href=\"Encounter-example-encounter-phone.html\">Encounter: status = finished; class = virtual (ActCode#VR); type = ; serviceType = ; period = 2026-01-29 09:00:00+0100 --&gt; 2026-01-29 09:10:00+0100</a></li><li><a href=\"Encounter-example-encounter-evaluation.html\">Encounter: status = finished; class = ambulatory (ActCode#AMB); type = ; serviceType = ; period = 2026-02-05 13:00:00+0100 --&gt; 2026-02-05 13:40:00+0100</a></li><li><a href=\"Encounter-example-short-term-stay.html\">Encounter: status = finished; class = inpatient encounter (ActCode#IMP); type = ; serviceType = ; period = 2026-01-13 15:00:00+0100 --&gt; 2026-01-15 09:30:00+0100</a></li></ul><p><b>reference</b>: <a href=\"ServiceRequest-example-servicerequest.html\">ServiceRequest </a></p></blockquote><blockquote><p><b>activity</b></p><p><b>reference</b>: <a href=\"Appointment-example-appointment.html\">Appointment: status = booked; serviceType = ; appointmentType = ; description = Planned home visit for medication follow-up and function assessment; start = 2026-01-22 11:00:00+0100; end = 2026-01-22 11:30:00+0100; created = 2026-01-13 12:00:00+0100</a></p></blockquote><blockquote><p><b>activity</b></p><p><b>outcomeReference</b>: <a href=\"Encounter-example-encounter-evaluation.html\">Encounter: status = finished; class = ambulatory (ActCode#AMB); type = ; serviceType = ; period = 2026-02-05 13:00:00+0100 --&gt; 2026-02-05 13:40:00+0100</a></p><p><b>reference</b>: <a href=\"ServiceRequest-example-rehabilitation-servicerequest.html\">ServiceRequest </a></p></blockquote></div>"
  ] ;
  fhir:CarePlan.status [ fhir:value "active"] ;
  fhir:CarePlan.intent [ fhir:value "plan"] ;
  fhir:CarePlan.category [
     fhir:index -1 ;
     fhir:CodeableConcept.text [ fhir:value "Municipal follow-up" ]
  ] ;
  fhir:CarePlan.title [ fhir:value "Follow-up plan after discharge - Grünerløkka district"] ;
  fhir:CarePlan.subject [
     fhir:link <http://hl7.org/fhir/Patient/example-patient> ;
     fhir:Reference.reference [ fhir:value "Patient/example-patient" ]
  ] ;
  fhir:CarePlan.period [
     fhir:Period.start [ fhir:value "2026-01-13"^^xsd:date ] ;
     fhir:Period.end [ fhir:value "2026-03-31"^^xsd:date ]
  ] ;
  fhir:CarePlan.author [
     fhir:link <http://hl7.org/fhir/PractitionerRole/example-practitionerrole> ;
     fhir:Reference.reference [ fhir:value "PractitionerRole/example-practitionerrole" ]
  ] ;
  fhir:CarePlan.careTeam [
     fhir:index -1 ;
     fhir:link <http://hl7.org/fhir/CareTeam/example-careteam> ;
     fhir:Reference.reference [ fhir:value "CareTeam/example-careteam" ]
  ] ;
  fhir:CarePlan.addresses [
     fhir:index -1 ;
     fhir:link <http://hl7.org/fhir/Condition/example-health-concern> ;
     fhir:Reference.reference [ fhir:value "Condition/example-health-concern" ] ;
     fhir:Reference.display [ fhir:value "Health concern after hip fracture" ]
  ] ;
  fhir:CarePlan.supportingInfo [
     fhir:index -1 ;
     fhir:link <http://hl7.org/fhir/Condition/example-health-concern> ;
     fhir:Reference.reference [ fhir:value "Condition/example-health-concern" ] ;
     fhir:Reference.display [ fhir:value "Health concern after hip fracture" ]
  ], [
     fhir:index -1 ;
     fhir:link <http://hl7.org/fhir/Observation/example-observation> ;
     fhir:Reference.reference [ fhir:value "Observation/example-observation" ]
  ], [
     fhir:index -1 ;
     fhir:link <http://hl7.org/fhir/DocumentReference/example-documentreference> ;
     fhir:Reference.reference [ fhir:value "DocumentReference/example-documentreference" ]
  ], [
     fhir:index -1 ;
     fhir:link <http://hl7.org/fhir/Goal/example-goal> ;
     fhir:Reference.reference [ fhir:value "Goal/example-goal" ]
  ] ;
  fhir:CarePlan.goal [
     fhir:index -1 ;
     fhir:link <http://hl7.org/fhir/Goal/example-goal> ;
     fhir:Reference.reference [ fhir:value "Goal/example-goal" ]
  ] ;
  fhir:CarePlan.activity [
     fhir:index -1 ;
     fhir:CarePlan.activity.outcomeReference [
       fhir:index -1 ;
       fhir:link <http://hl7.org/fhir/Encounter/example-encounter> ;
       fhir:Reference.reference [ fhir:value "Encounter/example-encounter" ]
     ], [
       fhir:index -1 ;
       fhir:link <http://hl7.org/fhir/Encounter/example-encounter-followup> ;
       fhir:Reference.reference [ fhir:value "Encounter/example-encounter-followup" ]
     ], [
       fhir:index -1 ;
       fhir:link <http://hl7.org/fhir/Encounter/example-encounter-phone> ;
       fhir:Reference.reference [ fhir:value "Encounter/example-encounter-phone" ]
     ], [
       fhir:index -1 ;
       fhir:link <http://hl7.org/fhir/Encounter/example-encounter-evaluation> ;
       fhir:Reference.reference [ fhir:value "Encounter/example-encounter-evaluation" ]
     ], [
       fhir:index -1 ;
       fhir:link <http://hl7.org/fhir/Encounter/example-short-term-stay> ;
       fhir:Reference.reference [ fhir:value "Encounter/example-short-term-stay" ]
     ] ;
     fhir:CarePlan.activity.reference [
       fhir:link <http://hl7.org/fhir/ServiceRequest/example-servicerequest> ;
       fhir:Reference.reference [ fhir:value "ServiceRequest/example-servicerequest" ]
     ]
  ], [
     fhir:index -1 ;
     fhir:CarePlan.activity.reference [
       fhir:link <http://hl7.org/fhir/Appointment/example-appointment> ;
       fhir:Reference.reference [ fhir:value "Appointment/example-appointment" ]
     ]
  ], [
     fhir:index -1 ;
     fhir:CarePlan.activity.outcomeReference [
       fhir:index -1 ;
       fhir:link <http://hl7.org/fhir/Encounter/example-encounter-evaluation> ;
       fhir:Reference.reference [ fhir:value "Encounter/example-encounter-evaluation" ]
     ] ;
     fhir:CarePlan.activity.reference [
       fhir:link <http://hl7.org/fhir/ServiceRequest/example-rehabilitation-servicerequest> ;
       fhir:Reference.reference [ fhir:value "ServiceRequest/example-rehabilitation-servicerequest" ]
     ]
  ] .

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

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

<http://hl7.org/fhir/CareTeam/example-careteam> a fhir:CareTeam .

<http://hl7.org/fhir/Condition/example-health-concern> a fhir:Condition .

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

<http://hl7.org/fhir/DocumentReference/example-documentreference> a fhir:DocumentReference .

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

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

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

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

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

<http://hl7.org/fhir/Encounter/example-short-term-stay> a fhir:Encounter .

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

<http://hl7.org/fhir/Appointment/example-appointment> a fhir:Appointment .

<http://hl7.org/fhir/ServiceRequest/example-rehabilitation-servicerequest> a fhir:ServiceRequest .

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

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