{
  "resourceType": "StructureDefinition",
  "url": "https://fhir.siss.regione.lombardia.it/StructureDefinition/RLCompositionRSA",
  "name": "RLCompositionRSA",
  "title": "Composition RSA",
  "status": "draft",
  "date": "2026-10-07",
  "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 di Specialistica Ambulatoriale"
      },
      {
        "id": "Composition.extension",
        "path": "Composition.extension",
        "slicing": {
          "discriminator": [
            {
              "type": "value",
              "path": "url"
            }
          ],
          "ordered": false,
          "rules": "open"
        }
      },
      {
        "id": "Composition.extension:dataEnterer",
        "path": "Composition.extension",
        "sliceName": "dataEnterer",
        "short": "Persona o dispositivo che trasforma un testo dettato nel documento FHIR",
        "comment": "Fare riferimento a: http://hl7.it/fhir/StructureDefinition/composition-dataenterer-it (riferimento a PractitionerRoleCore)",
        "min": 0,
        "max": "*",
        "type": [
          {
            "code": "Extension",
            "profile": [
              "http://hl7.it/fhir/StructureDefinition/composition-dataenterer-it"
            ]
          }
        ]
      },
      {
        "id": "Composition.extension:versionNumber",
        "path": "Composition.extension",
        "sliceName": "versionNumber",
        "short": "Identificatore specifico della versione per la composizione, assegnato quando ciascuna versione viene creata o aggiornata",
        "comment": "Fare riferimento a: http://hl7.org/fhir/StructureDefinition/composition-clinicaldocument-versionNumber",
        "min": 0,
        "max": "1",
        "type": [
          {
            "code": "Extension",
            "profile": [
              "http://hl7.org/fhir/StructureDefinition/composition-clinicaldocument-versionNumber"
            ]
          }
        ]
      },
      {
        "id": "Composition.extension:basedOn",
        "path": "Composition.extension",
        "sliceName": "basedOn",
        "short": "Richiesta che ha determinato la produzione del documento",
        "comment": "Numero ricetta medica, Codice CUP, Codici identificazione oggetti correlati. L'extension referenzia la ServiceRequestCore, seguendo l'esempio del Referto di Laboratorio; il Medico Prescrittore è rappresentato in ServiceRequest.requester (Reference(PractitionerRoleCore)).",
        "min": 0,
        "max": "*",
        "type": [
          {
            "code": "Extension",
            "profile": [
              "http://hl7.eu/fhir/laboratory/StructureDefinition/composition-basedOn-order-or-requisition"
            ]
          }
        ]
      },
      {
        "id": "Composition.status",
        "path": "Composition.status",
        "short": "Stato del documento",
        "min": 1,
        "max": "1",
        "fixedCode": "final"
      },
      {
        "id": "Composition.type",
        "path": "Composition.type",
        "short": "Identifica la tipologia di documento a cui il documento si riferisce",
        "min": 1,
        "max": "1"
      },
      {
        "id": "Composition.type.coding",
        "path": "Composition.type.coding",
        "min": 1,
        "max": "*"
      },
      {
        "id": "Composition.type.coding.system",
        "path": "Composition.type.coding.system",
        "short": "Sistema di codifica",
        "comment": "LOINC (OID 2.16.840.1.113883.6.1)",
        "min": 0,
        "max": "1",
        "fixedUri": "http://loinc.org"
      },
      {
        "id": "Composition.type.coding.version",
        "path": "Composition.type.coding.version",
        "short": "Versione del sistema di codifica",
        "comment": "Es. LOINC 2.19",
        "min": 0,
        "max": "1"
      },
      {
        "id": "Composition.type.coding.code",
        "path": "Composition.type.coding.code",
        "short": "Codice locale per il tipo di documento",
        "min": 0,
        "max": "1",
        "fixedCode": "11488-4"
      },
      {
        "id": "Composition.type.coding.display",
        "path": "Composition.type.coding.display",
        "short": "Descrizione leggibile del sistema locale",
        "min": 0,
        "max": "1",
        "fixedString": "Nota di consulto"
      },
      {
        "id": "Composition.subject",
        "path": "Composition.subject",
        "short": "Codifica i dati identificativi ed anagrafici del paziente",
        "comment": "Assistito",
        "min": 0,
        "max": "1",
        "type": [
          {
            "code": "Reference",
            "targetProfile": [
              "https://fhir.siss.regione.lombardia.it/StructureDefinition/RLPatientCore"
            ]
          }
        ]
      },
      {
        "id": "Composition.encounter",
        "path": "Composition.encounter",
        "short": "Rappresenta coloro coinvolti nell'atto descritto",
        "comment": "Codice nosologico, Tecnico. Il codice e la descrizione dell'unità operativa (Provenienza) vanno rappresentati in Encounter.location.location (LocationCore); il codice e la descrizione del presidio in Location.managingOrganization (OrganizationCore).",
        "min": 0,
        "max": "1",
        "type": [
          {
            "code": "Reference",
            "targetProfile": [
              "https://fhir.siss.regione.lombardia.it/StructureDefinition/RLEncounterCore"
            ]
          }
        ]
      },
      {
        "id": "Composition.date",
        "path": "Composition.date",
        "short": "Giorno e ora della creazione dell'istanza del documento",
        "min": 1,
        "max": "1"
      },
      {
        "id": "Composition.author",
        "path": "Composition.author",
        "short": "Autore del documento (Medico Refertante e/o dispositivo/applicazione software che ha generato il documento)",
        "comment": "Medico Refertante: PractitionerRoleCore o PractitionerCore. Device: dispositivo e/o applicazione software che ha generato il documento.",
        "min": 1,
        "max": "*",
        "type": [
          {
            "code": "Reference",
            "targetProfile": [
              "https://fhir.siss.regione.lombardia.it/StructureDefinition/RLPractitionerRoleCore",
              "https://fhir.siss.regione.lombardia.it/StructureDefinition/RLPractitionerCore",
              "http://hl7.org/fhir/StructureDefinition/Device"
            ]
          }
        ]
      },
      {
        "id": "Composition.title",
        "path": "Composition.title",
        "short": "L'elemento title specifica il titolo del documento",
        "min": 1,
        "max": "1",
        "fixedString": "Referto di Specialistica Ambulatoriale"
      },
      {
        "id": "Composition.attester",
        "path": "Composition.attester",
        "short": "Professionisti che attestano la validità del documento",
        "comment": "Se la risorsa è creata a fine documentale uno degli attester dovrebbe essere il firmatario, ovvero chi allega la firma digitale al documento.",
        "slicing": {
          "discriminator": [
            {
              "type": "value",
              "path": "mode"
            }
          ],
          "ordered": false,
          "rules": "open"
        },
        "min": 1,
        "max": "*"
      },
      {
        "id": "Composition.attester:legalAuthenticator",
        "path": "Composition.attester",
        "sliceName": "legalAuthenticator",
        "short": "Firmatario del documento FHIR",
        "comment": "Medico Firmatario",
        "min": 0,
        "max": "1"
      },
      {
        "id": "Composition.attester:legalAuthenticator.mode",
        "path": "Composition.attester.mode",
        "short": "Identificazione del firmatario tra gli attester FHIR",
        "min": 1,
        "max": "1",
        "fixedCode": "legal"
      },
      {
        "id": "Composition.attester:legalAuthenticator.time",
        "path": "Composition.attester.time",
        "short": "Quando è stato firmato il documento",
        "comment": "Data e ora di firma",
        "min": 1,
        "max": "1"
      },
      {
        "id": "Composition.attester:legalAuthenticator.party",
        "path": "Composition.attester.party",
        "short": "Riferimento al firmatario",
        "min": 0,
        "max": "1",
        "type": [
          {
            "code": "Reference",
            "targetProfile": [
              "https://fhir.siss.regione.lombardia.it/StructureDefinition/RLPractitionerRoleCore",
              "https://fhir.siss.regione.lombardia.it/StructureDefinition/RLPractitionerCore"
            ]
          }
        ]
      },
      {
        "id": "Composition.custodian",
        "path": "Composition.custodian",
        "short": "Organizzazione responsabile della conservazione dell'originale del documento, al momento della generazione",
        "comment": "Azienda Sanitaria: codice e descrizione azienda sanitaria",
        "min": 0,
        "max": "1",
        "type": [
          {
            "code": "Reference",
            "targetProfile": [
              "https://fhir.siss.regione.lombardia.it/StructureDefinition/RLOrganizationCore"
            ]
          }
        ]
      },
      {
        "id": "Composition.event",
        "path": "Composition.event",
        "short": "La prestazione specialistica documentata",
        "comment": "Tipologia di accesso",
        "min": 0,
        "max": "*"
      },
      {
        "id": "Composition.event.detail",
        "path": "Composition.event.detail",
        "short": "Soggetto che effettua il serviceEvent",
        "min": 0,
        "max": "*",
        "type": [
          {
            "code": "Reference",
            "targetProfile": [
              "https://fhir.siss.regione.lombardia.it/StructureDefinition/RLPractitionerRoleCore"
            ]
          }
        ]
      },
      {
        "id": "Composition.section",
        "path": "Composition.section",
        "slicing": {
          "discriminator": [
            {
              "type": "pattern",
              "path": "code"
            }
          ],
          "ordered": false,
          "rules": "open"
        }
      },
      {
        "id": "Composition.section:storiaClinica",
        "path": "Composition.section",
        "sliceName": "storiaClinica",
        "short": "Storia Clinica",
        "min": 0,
        "max": "1"
      },
      {
        "id": "Composition.section:storiaClinica.title",
        "path": "Composition.section.title",
        "short": "Titolo della sezione",
        "min": 0,
        "max": "1",
        "fixedString": "Storia Clinica"
      },
      {
        "id": "Composition.section:storiaClinica.code",
        "path": "Composition.section.code",
        "short": "Codice che identifica il tipo di sezione",
        "min": 0,
        "max": "1",
        "patternCodeableConcept": {
          "coding": [
            {
              "system": "http://loinc.org",
              "code": "11329-0"
            }
          ]
        }
      },
      {
        "id": "Composition.section:storiaClinica.code.coding.system",
        "path": "Composition.section.code.coding.system",
        "short": "Sistema di codifica",
        "comment": "LOINC (OID 2.16.840.1.113883.6.1)",
        "min": 0,
        "max": "1",
        "fixedUri": "http://loinc.org"
      },
      {
        "id": "Composition.section:storiaClinica.code.coding.version",
        "path": "Composition.section.code.coding.version",
        "short": "Versione del sistema di codifica",
        "comment": "Es. LOINC 2.19",
        "min": 0,
        "max": "1"
      },
      {
        "id": "Composition.section:storiaClinica.code.coding.code",
        "path": "Composition.section.code.coding.code",
        "short": "Valore del codice",
        "min": 0,
        "max": "1",
        "fixedCode": "11329-0"
      },
      {
        "id": "Composition.section:storiaClinica.code.coding.display",
        "path": "Composition.section.code.coding.display",
        "short": "Descrizione leggibile del codice",
        "min": 0,
        "max": "1",
        "fixedString": "Storia Generale"
      },
      {
        "id": "Composition.section:storiaClinica.text",
        "path": "Composition.section.text",
        "short": "Sintesi testuale della sezione",
        "min": 0,
        "max": "1"
      },
      {
        "id": "Composition.section:storiaClinica.entry",
        "path": "Composition.section.entry",
        "slicing": {
          "discriminator": [
            {
              "type": "profile",
              "path": "resolve()"
            }
          ],
          "ordered": false,
          "rules": "open"
        },
        "min": 0
      },
      {
        "id": "Composition.section:storiaClinica.entry:observation",
        "path": "Composition.section.entry",
        "sliceName": "observation",
        "short": "Storia clinica",
        "min": 0,
        "max": "2",
        "type": [
          {
            "code": "Reference",
            "targetProfile": [
              "https://fhir.siss.regione.lombardia.it/StructureDefinition/RLObservationStoriaClinica"
            ]
          }
        ]
      },
      {
        "id": "Composition.section:storiaClinica.entry:familyMemberHistory",
        "path": "Composition.section.entry",
        "sliceName": "familyMemberHistory",
        "short": "Anamnesi familiare",
        "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": "pattern",
              "path": "code"
            }
          ],
          "ordered": false,
          "rules": "open"
        }
      },
      {
        "id": "Composition.section:storiaClinica.section:allergie",
        "path": "Composition.section.section",
        "sliceName": "allergie",
        "short": "Allergie",
        "min": 0,
        "max": "1"
      },
      {
        "id": "Composition.section:storiaClinica.section:allergie.title",
        "path": "Composition.section.section.title",
        "short": "Titolo della sezione",
        "min": 0,
        "max": "1",
        "fixedString": "Allergie e/o reazioni avverse"
      },
      {
        "id": "Composition.section:storiaClinica.section:allergie.code",
        "path": "Composition.section.section.code",
        "short": "Codice che identifica il tipo di sezione",
        "min": 0,
        "max": "1",
        "patternCodeableConcept": {
          "coding": [
            {
              "system": "http://loinc.org",
              "code": "48765-2"
            }
          ]
        }
      },
      {
        "id": "Composition.section:storiaClinica.section:allergie.code.coding.system",
        "path": "Composition.section.section.code.coding.system",
        "short": "Sistema di codifica",
        "comment": "LOINC (OID 2.16.840.1.113883.6.1)",
        "min": 0,
        "max": "1",
        "fixedUri": "http://loinc.org"
      },
      {
        "id": "Composition.section:storiaClinica.section:allergie.code.coding.version",
        "path": "Composition.section.section.code.coding.version",
        "short": "Versione del sistema di codifica",
        "comment": "Es. LOINC 2.19",
        "min": 0,
        "max": "1"
      },
      {
        "id": "Composition.section:storiaClinica.section:allergie.code.coding.code",
        "path": "Composition.section.section.code.coding.code",
        "short": "Valore del codice",
        "min": 0,
        "max": "1",
        "fixedCode": "48765-2"
      },
      {
        "id": "Composition.section:storiaClinica.section:allergie.code.coding.display",
        "path": "Composition.section.section.code.coding.display",
        "short": "Descrizione leggibile del codice",
        "min": 0,
        "max": "1",
        "fixedString": "Allergie e/o reazioni avverse"
      },
      {
        "id": "Composition.section:storiaClinica.section:allergie.entry",
        "path": "Composition.section.section.entry",
        "short": "Allergie e/o reazioni avverse",
        "min": 0,
        "max": "*",
        "type": [
          {
            "code": "Reference",
            "targetProfile": [
              "https://fhir.siss.regione.lombardia.it/StructureDefinition/RLAllergyIntoleranceCore"
            ]
          }
        ]
      },
      {
        "id": "Composition.section:storiaClinica.section:terapiaInAtto",
        "path": "Composition.section.section",
        "sliceName": "terapiaInAtto",
        "short": "Terapia farmacologica in atto",
        "min": 0,
        "max": "1"
      },
      {
        "id": "Composition.section:storiaClinica.section:terapiaInAtto.title",
        "path": "Composition.section.section.title",
        "short": "Titolo della sezione",
        "min": 0,
        "max": "1",
        "fixedString": "Terapia Farmacologica in Atto"
      },
      {
        "id": "Composition.section:storiaClinica.section:terapiaInAtto.code",
        "path": "Composition.section.section.code",
        "short": "Codice che identifica il tipo di sezione",
        "min": 0,
        "max": "1",
        "patternCodeableConcept": {
          "coding": [
            {
              "system": "http://loinc.org",
              "code": "10160-0"
            }
          ]
        }
      },
      {
        "id": "Composition.section:storiaClinica.section:terapiaInAtto.code.coding.system",
        "path": "Composition.section.section.code.coding.system",
        "short": "Sistema di codifica",
        "comment": "LOINC (OID 2.16.840.1.113883.6.1)",
        "min": 0,
        "max": "1",
        "fixedUri": "http://loinc.org"
      },
      {
        "id": "Composition.section:storiaClinica.section:terapiaInAtto.code.coding.version",
        "path": "Composition.section.section.code.coding.version",
        "short": "Versione del sistema di codifica",
        "comment": "Es. LOINC 2.19",
        "min": 0,
        "max": "1"
      },
      {
        "id": "Composition.section:storiaClinica.section:terapiaInAtto.code.coding.code",
        "path": "Composition.section.section.code.coding.code",
        "short": "Valore del codice",
        "min": 0,
        "max": "1",
        "fixedCode": "10160-0"
      },
      {
        "id": "Composition.section:storiaClinica.section:terapiaInAtto.code.coding.display",
        "path": "Composition.section.section.code.coding.display",
        "short": "Descrizione leggibile del codice",
        "min": 0,
        "max": "1"
      },
      {
        "id": "Composition.section:storiaClinica.section:terapiaInAtto.text",
        "path": "Composition.section.section.text",
        "short": "Descrizione terapia farmacologica",
        "min": 0,
        "max": "1"
      },
      {
        "id": "Composition.section:storiaClinica.section:terapiaInAtto.entry",
        "path": "Composition.section.section.entry",
        "short": "Codice AIC/ATC farmaco",
        "min": 0,
        "max": "1",
        "type": [
          {
            "code": "Reference",
            "targetProfile": [
              "https://fhir.siss.regione.lombardia.it/StructureDefinition/RLMedicationStatementTerapiaFarmacologica"
            ]
          }
        ]
      },
      {
        "id": "Composition.section:quesitoDiagnostico",
        "path": "Composition.section",
        "sliceName": "quesitoDiagnostico",
        "short": "Quesito Diagnostico",
        "min": 0,
        "max": "1"
      },
      {
        "id": "Composition.section:quesitoDiagnostico.title",
        "path": "Composition.section.title",
        "short": "Titolo della sezione",
        "min": 0,
        "max": "1",
        "fixedString": "Quesito Diagnostico"
      },
      {
        "id": "Composition.section:quesitoDiagnostico.code",
        "path": "Composition.section.code",
        "short": "Codice che identifica il tipo di sezione",
        "min": 0,
        "max": "1",
        "patternCodeableConcept": {
          "coding": [
            {
              "system": "http://loinc.org",
              "code": "29299-5"
            }
          ]
        }
      },
      {
        "id": "Composition.section:quesitoDiagnostico.code.coding.system",
        "path": "Composition.section.code.coding.system",
        "short": "Sistema di codifica",
        "comment": "LOINC (OID 2.16.840.1.113883.6.1)",
        "min": 0,
        "max": "1",
        "fixedUri": "http://loinc.org"
      },
      {
        "id": "Composition.section:quesitoDiagnostico.code.coding.version",
        "path": "Composition.section.code.coding.version",
        "short": "Versione del sistema di codifica",
        "comment": "Es. LOINC 2.19",
        "min": 0,
        "max": "1"
      },
      {
        "id": "Composition.section:quesitoDiagnostico.code.coding.code",
        "path": "Composition.section.code.coding.code",
        "short": "Valore del codice",
        "min": 0,
        "max": "1",
        "fixedCode": "29299-5"
      },
      {
        "id": "Composition.section:quesitoDiagnostico.code.coding.display",
        "path": "Composition.section.code.coding.display",
        "short": "Descrizione leggibile del codice",
        "min": 0,
        "max": "1",
        "fixedString": "Motivo della visita"
      },
      {
        "id": "Composition.section:quesitoDiagnostico.text",
        "path": "Composition.section.text",
        "short": "Descrizione quesito diagnostico",
        "min": 0,
        "max": "1"
      },
      {
        "id": "Composition.section:quesitoDiagnostico.entry",
        "path": "Composition.section.entry",
        "short": "Codice quesito diagnostico",
        "min": 0,
        "max": "1",
        "type": [
          {
            "code": "Reference",
            "targetProfile": [
              "https://fhir.siss.regione.lombardia.it/StructureDefinition/RLObservationQuesitoDiagnostico"
            ]
          }
        ]
      },
      {
        "id": "Composition.section:precedentiEsami",
        "path": "Composition.section",
        "sliceName": "precedentiEsami",
        "short": "Precedenti Esami Eseguiti",
        "min": 0,
        "max": "1"
      },
      {
        "id": "Composition.section:precedentiEsami.title",
        "path": "Composition.section.title",
        "short": "Titolo della sezione",
        "min": 0,
        "max": "1",
        "fixedString": "Precedenti Esami Eseguiti"
      },
      {
        "id": "Composition.section:precedentiEsami.code",
        "path": "Composition.section.code",
        "short": "Codice che identifica il tipo di sezione",
        "min": 0,
        "max": "1",
        "patternCodeableConcept": {
          "coding": [
            {
              "system": "http://loinc.org",
              "code": "30954-2"
            }
          ]
        }
      },
      {
        "id": "Composition.section:precedentiEsami.code.coding.system",
        "path": "Composition.section.code.coding.system",
        "short": "Sistema di codifica",
        "comment": "LOINC (OID 2.16.840.1.113883.6.1)",
        "min": 0,
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        "fixedUri": "http://loinc.org"
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        "id": "Composition.section:precedentiEsami.code.coding.version",
        "path": "Composition.section.code.coding.version",
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        "comment": "Es. LOINC 2.19",
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      },
      {
        "id": "Composition.section:precedentiEsami.code.coding.code",
        "path": "Composition.section.code.coding.code",
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        "fixedCode": "30954-2"
      },
      {
        "id": "Composition.section:precedentiEsami.code.coding.display",
        "path": "Composition.section.code.coding.display",
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      {
        "id": "Composition.section:precedentiEsami.entry",
        "path": "Composition.section.entry",
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        "fixedString": "Esame Obiettivo"
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      {
        "id": "Composition.section:esameObiettivo.code",
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        "patternCodeableConcept": {
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        "id": "Composition.section:esameObiettivo.code.coding.system",
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        "id": "Composition.section:esameObiettivo.code.coding.version",
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      {
        "id": "Composition.section:esameObiettivo.code.coding.code",
        "path": "Composition.section.code.coding.code",
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        "id": "Composition.section:esameObiettivo.code.coding.display",
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        "patternCodeableConcept": {
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        "fixedString": "Interventi"
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        "min": 0,
        "max": "1"
      },
      {
        "id": "Composition.section:prestazioni.entry",
        "path": "Composition.section.entry",
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        "max": "*",
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      {
        "id": "Composition.section:confrontoPrecedentiEsami",
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      },
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        "fixedString": "Confronto con Precedenti Esami Eseguiti"
      },
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        "id": "Composition.section:confrontoPrecedentiEsami.code",
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        "id": "Composition.section:confrontoPrecedentiEsami.code.coding.version",
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      },
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        "fixedString": "Referto"
      },
      {
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      },
      {
        "id": "Composition.section:referto.code.coding.code",
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        "fixedString": "Diagnosi"
      },
      {
        "id": "Composition.section:diagnosi.code",
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        "min": 0,
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        "patternCodeableConcept": {
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      },
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        "id": "Composition.section:diagnosi.code.coding.system",
        "path": "Composition.section.code.coding.system",
        "short": "Sistema di codifica",
        "comment": "LOINC (OID 2.16.840.1.113883.6.1)",
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        "fixedUri": "http://loinc.org"
      },
      {
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      {
        "id": "Composition.section:diagnosi.code.coding.code",
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        "min": 0,
        "max": "1",
        "fixedCode": "29548-5"
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      {
        "id": "Composition.section:diagnosi.code.coding.display",
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        "min": 0,
        "max": "1"
      },
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        "id": "Composition.section:diagnosi.entry",
        "path": "Composition.section.entry",
        "short": "Codice diagnosi",
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        "max": "1",
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        "fixedString": "Conclusioni"
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      {
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        "patternCodeableConcept": {
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      },
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        "short": "Sistema di codifica",
        "comment": "LOINC (OID 2.16.840.1.113883.6.1)",
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        "fixedUri": "http://loinc.org"
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      },
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        "fixedString": "Suggerimenti per il Medico Prescrittore"
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        "id": "Composition.section:suggerimentiMedicoPrescrittore.code",
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        "patternCodeableConcept": {
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            "targetProfile": [
              "https://fhir.siss.regione.lombardia.it/StructureDefinition/RLMedicationRequestTerapiaFarmacologicaConsigliataRSA"
            ]
          }
        ]
      }
    ]
  }
}