{
  "resourceType": "StructureDefinition",
  "url": "https://fhir.siss.regione.lombardia.it/StructureDefinition/RLCompositionRefertoRadiologia",
  "name": "RLCompositionRefertoRadiologia",
  "title": "RL Composition Referto Radiologia",
  "status": "draft",
  "fhirVersion": "4.0.1",
  "kind": "resource",
  "abstract": false,
  "type": "Composition",
  "baseDefinition": "http://hl7.org/fhir/StructureDefinition/Composition",
  "derivation": "constraint",
  "differential": {
    "element": [
      {
        "id": "Composition",
        "path": "Composition",
        "short": "Referto Radiologico",
        "definition": "Documento FHIR che rappresenta il Referto Radiologico prodotto nell'ambito SISS Regione Lombardia."
      },
      {
        "id": "Composition.type",
        "path": "Composition.type",
        "short": "Identifica la tipologia di documento",
        "min": 1,
        "max": "1"
      },
      {
        "id": "Composition.type.coding",
        "path": "Composition.type.coding",
        "min": 1,
        "max": "1"
      },
      {
        "id": "Composition.type.coding.system",
        "path": "Composition.type.coding.system",
        "min": 1,
        "max": "1",
        "fixedUri": "http://loinc.org",
        "definition": "Sistema di codifica.",
        "note": [
          {
            "text": "Fixed: LOINC (OID 2.16.840.1.113883.6.1)"
          }
        ]
      },
      {
        "id": "Composition.type.coding.version",
        "path": "Composition.type.coding.version",
        "min": 0,
        "max": "1",
        "definition": "Versione del sistema di codifica.",
        "example": [
          {
            "label": "Esempio",
            "valueString": "LOINC 2.19"
          }
        ]
      },
      {
        "id": "Composition.type.coding.code",
        "path": "Composition.type.coding.code",
        "min": 1,
        "max": "1",
        "fixedCode": "68604-8",
        "short": "Codice locale per il tipo di documento."
      },
      {
        "id": "Composition.type.coding.display",
        "path": "Composition.type.coding.display",
        "min": 0,
        "max": "1",
        "fixedString": "Referto Radiologico",
        "definition": "Descrizione leggibile del sistema locale."
      },
      {
        "id": "Composition.title",
        "path": "Composition.title",
        "min": 1,
        "max": "1",
        "fixedString": "Referto Radiologico",
        "definition": "L'elemento title specifica il titolo del documento."
      },
      {
        "id": "Composition.status",
        "path": "Composition.status",
        "min": 1,
        "max": "1",
        "definition": "Stato del documento.",
        "note": [
          {
            "text": "Valori ammessi: active | final. Suggerimento (non fixed): final."
          }
        ]
      },
      {
        "id": "Composition.date",
        "path": "Composition.date",
        "min": 1,
        "max": "1",
        "definition": "Giorno e ora della creazione dell'istanza del documento."
      },
      {
        "id": "Composition.subject",
        "path": "Composition.subject",
        "min": 1,
        "max": "1",
        "type": [
          {
            "code": "Reference",
            "targetProfile": [
              "https://fhir.siss.regione.lombardia.it/StructureDefinition/RLPatientCore"
            ]
          }
        ],
        "definition": "Paziente (Assistito) a cui si riferisce il documento.",
        "note": [
          {
            "text": "Cardinalità corretta a 1..1 rispetto alla fonte (0..1): il subject è sempre presente in un referto."
          }
        ]
      },
      {
        "id": "Composition.author",
        "path": "Composition.author",
        "min": 1,
        "max": "*",
        "type": [
          {
            "code": "Reference",
            "targetProfile": [
              "https://fhir.siss.regione.lombardia.it/StructureDefinition/RLPractitionerRoleCore",
              "https://fhir.siss.regione.lombardia.it/StructureDefinition/RLPractitionerCore",
              "https://fhir.siss.regione.lombardia.it/StructureDefinition/RLOrganizationCore"
            ]
          }
        ],
        "definition": "Medico Refertante: autore del documento. La reference identifica principalmente il professionista autore tramite PractitionerCore; se necessario rappresentare anche la struttura di appartenenza, usare PractitionerRoleCore."
      },
      {
        "id": "Composition.extension:dataEnterer",
        "path": "Composition.extension",
        "sliceName": "dataEnterer",
        "min": 0,
        "max": "*",
        "type": [
          {
            "code": "Extension",
            "profile": [
              "http://hl7.it/fhir/StructureDefinition/composition-dataenterer-it"
            ]
          }
        ],
        "definition": "Persona o dispositivo che trasforma un testo dettato nel documento FHIR."
      },
      {
        "id": "Composition.attester",
        "path": "Composition.attester",
        "min": 1,
        "max": "*",
        "definition": "Professionisti che attestano la validità del documento. Se la risorsa è creata a fine documentale, uno degli attester dovrebbe essere il firmatario (chi allega la firma digitale al documento).",
        "slicing": {
          "discriminator": [
            {
              "type": "value",
              "path": "mode"
            }
          ],
          "rules": "open"
        }
      },
      {
        "id": "Composition.attester:legalAuthenticator",
        "path": "Composition.attester",
        "sliceName": "legalAuthenticator",
        "min": 0,
        "max": "1",
        "short": "Medico Firmatario",
        "definition": "Firmatario del documento FHIR."
      },
      {
        "id": "Composition.attester:legalAuthenticator.mode",
        "path": "Composition.attester.mode",
        "min": 1,
        "max": "1",
        "fixedCode": "legal"
      },
      {
        "id": "Composition.attester:legalAuthenticator.time",
        "path": "Composition.attester.time",
        "min": 1,
        "max": "1",
        "short": "Data e ora di firma",
        "definition": "Riferimento temporale della firma."
      },
      {
        "id": "Composition.attester:legalAuthenticator.party",
        "path": "Composition.attester.party",
        "min": 0,
        "max": "1",
        "type": [
          {
            "code": "Reference",
            "targetProfile": [
              "https://fhir.siss.regione.lombardia.it/StructureDefinition/RLPractitionerCore",
              "https://fhir.siss.regione.lombardia.it/StructureDefinition/RLPractitionerRoleCore"
            ]
          }
        ],
        "definition": "Riferimento al firmatario."
      },
      {
        "id": "Composition.attester:authenticator",
        "path": "Composition.attester",
        "sliceName": "authenticator",
        "min": 0,
        "max": "1",
        "definition": "Validatore del documento FHIR."
      },
      {
        "id": "Composition.attester:authenticator.mode",
        "path": "Composition.attester.mode",
        "min": 1,
        "max": "1",
        "fixedCode": "professional"
      },
      {
        "id": "Composition.attester:authenticator.party",
        "path": "Composition.attester.party",
        "min": 0,
        "max": "1",
        "type": [
          {
            "code": "Reference",
            "targetProfile": [
              "https://fhir.siss.regione.lombardia.it/StructureDefinition/RLPractitionerCore",
              "https://fhir.siss.regione.lombardia.it/StructureDefinition/RLPractitionerRoleCore"
            ]
          }
        ],
        "definition": "Riferimento al validatore."
      },
      {
        "id": "Composition.custodian",
        "path": "Composition.custodian",
        "min": 0,
        "max": "1",
        "type": [
          {
            "code": "Reference",
            "targetProfile": [
              "https://fhir.siss.regione.lombardia.it/StructureDefinition/RLOrganizationCore"
            ]
          }
        ],
        "short": "Azienda Sanitaria",
        "definition": "Organizzazione responsabile della conservazione dell'originale del documento, al momento della generazione. Codice e descrizione dell'azienda sanitaria."
      },
      {
        "id": "Composition.extension:information-recipient",
        "path": "Composition.extension",
        "sliceName": "information-recipient",
        "min": 0,
        "max": "*",
        "type": [
          {
            "code": "Extension",
            "profile": [
              "http://hl7.eu/fhir/StructureDefinition/information-recipient"
            ]
          }
        ],
        "definition": "Professionisti sanitari che ricevono una copia del documento (es. MMG/PLS)."
      },
      {
        "id": "Composition.encounter",
        "path": "Composition.encounter",
        "min": 0,
        "max": "1",
        "type": [
          {
            "code": "Reference",
            "targetProfile": [
              "https://fhir.siss.regione.lombardia.it/StructureDefinition/RLEncounterCore"
            ]
          }
        ],
        "short": "Codice nosologico / Tecnico di radiologia",
        "definition": "Rappresenta l'atto/contesto assistenziale a cui il documento si riferisce (da cui, tramite EncounterCore, sono referenziabili Location e Organization: unità operativa, presidio, azienda sanitaria)."
      },
      {
        "id": "Composition.event",
        "path": "Composition.event",
        "min": 0,
        "max": "*",
        "short": "Tipologia di accesso",
        "definition": "Tipologia di accesso che ha determinato la prestazione."
      },
      {
        "id": "Composition.event.detail",
        "path": "Composition.event.detail",
        "min": 0,
        "max": "*",
        "type": [
          {
            "code": "Reference",
            "targetProfile": [
              "https://fhir.siss.regione.lombardia.it/StructureDefinition/RLPractitionerRoleCore"
            ]
          }
        ],
        "definition": "Soggetto che effettua il serviceEvent.",
        "note": [
          {
            "text": "Target uniformato a PractitionerRoleCore (la fonte riportava un'incoerenza tra path e colonna Tipo)."
          }
        ]
      },
      {
        "id": "Composition.basedOn",
        "path": "Composition.basedOn",
        "min": 0,
        "max": "*",
        "type": [
          {
            "code": "Reference",
            "targetProfile": [
              "https://fhir.siss.regione.lombardia.it/StructureDefinition/RLServiceRequestCore"
            ]
          }
        ],
        "short": "Numero ricetta medica / Codice CUP / Codice ordine interno / Accession Number / Studio DICOM",
        "definition": "Richiesta che ha determinato la produzione del documento di Referto di Radiologia o ogni altro ordine ad esso relativo.",
        "note": [
          {
            "text": "Il Medico Prescrittore è rintracciabile tramite ServiceRequestCore.requester (RLPractitionerRoleCore), non è un elemento proprio di questo profilo Composition."
          }
        ]
      },
      {
        "id": "Composition.extension:versionNumber",
        "path": "Composition.extension",
        "sliceName": "versionNumber",
        "min": 0,
        "max": "*",
        "type": [
          {
            "code": "Extension",
            "profile": [
              "http://hl7.org/fhir/StructureDefinition/composition-clinicaldocument-versionNumber"
            ]
          }
        ],
        "definition": "Identificatore specifico della versione per la composizione, assegnato quando ciascuna versione viene creata o aggiornata."
      },
      {
        "id": "Composition.section",
        "path": "Composition.section",
        "slicing": {
          "discriminator": [
            {
              "type": "value",
              "path": "code"
            }
          ],
          "rules": "open"
        },
        "min": 0,
        "max": "*"
      },
      {
        "id": "Composition.section:dicomObjectCatalog",
        "path": "Composition.section",
        "sliceName": "dicomObjectCatalog",
        "min": 0,
        "max": "1"
      },
      {
        "id": "Composition.section:dicomObjectCatalog.title",
        "path": "Composition.section.title",
        "min": 0,
        "max": "1",
        "fixedString": "DICOM Object Catalog"
      },
      {
        "id": "Composition.section:dicomObjectCatalog.code",
        "path": "Composition.section.code",
        "min": 0,
        "max": "1",
        "short": "Codice identificativo referto RIS"
      },
      {
        "id": "Composition.section:dicomObjectCatalog.code.coding.system",
        "path": "Composition.section.code.coding.system",
        "min": 0,
        "max": "1",
        "fixedUri": "urn:oid:1.2.840.10008.2.16.4",
        "note": [
          {
            "text": "Fixed: DCM"
          }
        ]
      },
      {
        "id": "Composition.section:dicomObjectCatalog.code.coding.version",
        "path": "Composition.section.code.coding.version",
        "min": 0,
        "max": "1"
      },
      {
        "id": "Composition.section:dicomObjectCatalog.code.coding.code",
        "path": "Composition.section.code.coding.code",
        "min": 0,
        "max": "1",
        "fixedCode": "121181"
      },
      {
        "id": "Composition.section:dicomObjectCatalog.code.coding.display",
        "path": "Composition.section.code.coding.display",
        "min": 0,
        "max": "1",
        "fixedString": "DICOM Object Catalog"
      },
      {
        "id": "Composition.section:dicomObjectCatalog.entry",
        "path": "Composition.section.entry",
        "min": 1,
        "max": "1",
        "type": [
          {
            "code": "Reference",
            "targetProfile": [
              "https://fhir.siss.regione.lombardia.it/StructureDefinition/RLImagingStudyDicom"
            ]
          }
        ]
      },
      {
        "id": "Composition.section:quesitoDiagnostico",
        "path": "Composition.section",
        "sliceName": "quesitoDiagnostico",
        "min": 0,
        "max": "1"
      },
      {
        "id": "Composition.section:quesitoDiagnostico.title",
        "path": "Composition.section.title",
        "min": 0,
        "max": "1",
        "fixedString": "Quesito Diagnostico"
      },
      {
        "id": "Composition.section:quesitoDiagnostico.code",
        "path": "Composition.section.code",
        "min": 0,
        "max": "1",
        "short": "Codice quesito diagnostico"
      },
      {
        "id": "Composition.section:quesitoDiagnostico.code.coding.system",
        "path": "Composition.section.code.coding.system",
        "min": 0,
        "max": "1",
        "fixedUri": "http://loinc.org",
        "note": [
          {
            "text": "Fixed: LOINC"
          }
        ]
      },
      {
        "id": "Composition.section:quesitoDiagnostico.code.coding.version",
        "path": "Composition.section.code.coding.version",
        "min": 0,
        "max": "1",
        "example": [
          {
            "label": "Esempio",
            "valueString": "LOINC 2.19"
          }
        ]
      },
      {
        "id": "Composition.section:quesitoDiagnostico.code.coding.code",
        "path": "Composition.section.code.coding.code",
        "min": 0,
        "max": "1",
        "fixedCode": "18785-6"
      },
      {
        "id": "Composition.section:quesitoDiagnostico.code.coding.display",
        "path": "Composition.section.code.coding.display",
        "min": 0,
        "max": "1",
        "short": "Descrizione quesito diagnostico",
        "definition": "Descrizione leggibile del codice (es. 'Motivo per lo studio - Radiologia')."
      },
      {
        "id": "Composition.section:quesitoDiagnostico.entry",
        "path": "Composition.section.entry",
        "min": 1,
        "max": "1",
        "type": [
          {
            "code": "Reference",
            "targetProfile": [
              "https://fhir.siss.regione.lombardia.it/StructureDefinition/RLObservationQuesitoDiagnostico"
            ]
          }
        ]
      },
      {
        "id": "Composition.section:storiaClinica",
        "path": "Composition.section",
        "sliceName": "storiaClinica",
        "min": 0,
        "max": "1",
        "short": "Anamnesi"
      },
      {
        "id": "Composition.section:storiaClinica.title",
        "path": "Composition.section.title",
        "min": 0,
        "max": "1",
        "fixedString": "Storia Clinica"
      },
      {
        "id": "Composition.section:storiaClinica.code",
        "path": "Composition.section.code",
        "min": 0,
        "max": "1"
      },
      {
        "id": "Composition.section:storiaClinica.code.coding.system",
        "path": "Composition.section.code.coding.system",
        "min": 0,
        "max": "1",
        "fixedUri": "http://loinc.org",
        "note": [
          {
            "text": "Fixed: LOINC"
          }
        ]
      },
      {
        "id": "Composition.section:storiaClinica.code.coding.version",
        "path": "Composition.section.code.coding.version",
        "min": 0,
        "max": "1",
        "example": [
          {
            "label": "Esempio",
            "valueString": "LOINC 2.19"
          }
        ]
      },
      {
        "id": "Composition.section:storiaClinica.code.coding.code",
        "path": "Composition.section.code.coding.code",
        "min": 0,
        "max": "1",
        "fixedCode": "11329-0"
      },
      {
        "id": "Composition.section:storiaClinica.code.coding.display",
        "path": "Composition.section.code.coding.display",
        "min": 0,
        "max": "1",
        "fixedString": "Storia Generale"
      },
      {
        "id": "Composition.section:storiaClinica.entry:condition",
        "path": "Composition.section.entry",
        "sliceName": "condition",
        "min": 0,
        "max": "2",
        "type": [
          {
            "code": "Reference",
            "targetProfile": [
              "https://fhir.siss.regione.lombardia.it/StructureDefinition/RLConditionCore"
            ]
          }
        ]
      },
      {
        "id": "Composition.section:storiaClinica.entry:familyMemberHistory",
        "path": "Composition.section.entry",
        "sliceName": "familyMemberHistory",
        "min": 0,
        "max": "2",
        "type": [
          {
            "code": "Reference",
            "targetProfile": [
              "https://fhir.siss.regione.lombardia.it/StructureDefinition/RLFamilyMemberHistoryCore"
            ]
          }
        ]
      },
      {
        "id": "Composition.section:storiaClinica.section",
        "path": "Composition.section.section",
        "slicing": {
          "discriminator": [
            {
              "type": "value",
              "path": "code"
            }
          ],
          "rules": "open"
        },
        "min": 0,
        "max": "*"
      },
      {
        "id": "Composition.section:storiaClinica.section:allergie",
        "path": "Composition.section.section",
        "sliceName": "allergie",
        "min": 0,
        "max": "*",
        "short": "Allergie"
      },
      {
        "id": "Composition.section:storiaClinica.section:allergie.title",
        "path": "Composition.section.section.title",
        "min": 0,
        "max": "1",
        "fixedString": "Allergie e/o reazione avversa"
      },
      {
        "id": "Composition.section:storiaClinica.section:allergie.code",
        "path": "Composition.section.section.code",
        "min": 0,
        "max": "1"
      },
      {
        "id": "Composition.section:storiaClinica.section:allergie.code.coding.system",
        "path": "Composition.section.section.code.coding.system",
        "min": 0,
        "max": "1",
        "fixedUri": "http://loinc.org",
        "note": [
          {
            "text": "Fixed: LOINC"
          }
        ]
      },
      {
        "id": "Composition.section:storiaClinica.section:allergie.code.coding.version",
        "path": "Composition.section.section.code.coding.version",
        "min": 0,
        "max": "1",
        "example": [
          {
            "label": "Esempio",
            "valueString": "LOINC 2.19"
          }
        ]
      },
      {
        "id": "Composition.section:storiaClinica.section:allergie.code.coding.code",
        "path": "Composition.section.section.code.coding.code",
        "min": 0,
        "max": "1",
        "fixedCode": "48765-2"
      },
      {
        "id": "Composition.section:storiaClinica.section:allergie.code.coding.display",
        "path": "Composition.section.section.code.coding.display",
        "min": 0,
        "max": "1",
        "fixedString": "Allergie e/o reazioni avverse"
      },
      {
        "id": "Composition.section:storiaClinica.section:allergie.entry",
        "path": "Composition.section.section.entry",
        "min": 0,
        "max": "*",
        "type": [
          {
            "code": "Reference",
            "targetProfile": [
              "https://fhir.siss.regione.lombardia.it/StructureDefinition/RLAllergyIntoleranceCore"
            ]
          }
        ],
        "note": [
          {
            "text": "Corretto refuso 'AllergyIntolleranceCore' -> RLAllergyIntoleranceCore, coerente con il resto dell'IG."
          }
        ]
      },
      {
        "id": "Composition.section:precedentiEsamiEseguiti",
        "path": "Composition.section",
        "sliceName": "precedentiEsamiEseguiti",
        "min": 0,
        "max": "1"
      },
      {
        "id": "Composition.section:precedentiEsamiEseguiti.title",
        "path": "Composition.section.title",
        "min": 0,
        "max": "1",
        "fixedString": "Precedenti Esami Eseguiti"
      },
      {
        "id": "Composition.section:precedentiEsamiEseguiti.code",
        "path": "Composition.section.code",
        "min": 0,
        "max": "1",
        "short": "Precedenti esami eseguiti"
      },
      {
        "id": "Composition.section:precedentiEsamiEseguiti.code.coding.system",
        "path": "Composition.section.code.coding.system",
        "min": 0,
        "max": "1",
        "fixedUri": "http://loinc.org",
        "note": [
          {
            "text": "Fixed: LOINC"
          }
        ]
      },
      {
        "id": "Composition.section:precedentiEsamiEseguiti.code.coding.version",
        "path": "Composition.section.code.coding.version",
        "min": 0,
        "max": "1",
        "example": [
          {
            "label": "Esempio",
            "valueString": "LOINC 2.19"
          }
        ]
      },
      {
        "id": "Composition.section:precedentiEsamiEseguiti.code.coding.code",
        "path": "Composition.section.code.coding.code",
        "min": 0,
        "max": "1",
        "fixedCode": "55114-3"
      },
      {
        "id": "Composition.section:precedentiEsamiEseguiti.code.coding.display",
        "path": "Composition.section.code.coding.display",
        "min": 0,
        "max": "1",
        "fixedString": "Precedente procedura di imaging, descrizioni"
      },
      {
        "id": "Composition.section:precedentiEsamiEseguiti.entry",
        "path": "Composition.section.entry",
        "min": 0,
        "max": "1",
        "type": [
          {
            "code": "Reference",
            "targetProfile": [
              "https://fhir.siss.regione.lombardia.it/StructureDefinition/RLObservationPrecedentiEsamiEseguiti"
            ]
          }
        ]
      },
      {
        "id": "Composition.section:esameEseguito",
        "path": "Composition.section",
        "sliceName": "esameEseguito",
        "min": 1,
        "max": "1"
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