Component 10 – Fundamentals

of Health Workflow Process

Analysis and Redesign
Unit 3-2 – Process Mapping
ISO 5807
This material was developed by Duke University, funded by the Department of Health and Human Services, Office of the National Coordinator for
Health Information Technology under Award Number IU24OC000024.
Upon successful completion of this
Subunit the student is able to:

• Describe standard ISO 5807 processing diagramming

symbols and conventions
• Analyze an existing ISO 5807 workflow process
diagram in terms of the information that could be
generated and the workflow steps that are being
communicated
• Create an ISO 5807 process diagram for a health care
system (or system component) using correct symbols
and conventions

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 Methods for Diagramming
Processes
ISO Yourdon Gane- UML E-R
Process Aspects 5807 Sarson diagram
Context X
Process steps X X X X
Information content X X
Information transformation X X X X
Sequencing / control / state X X
Roles involved X X

*UML extends beyond basic process features and models other aspects such as sequence, communication, and interrelationships.
We do not cover these aspects here.

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 Flowchart

• A graphic depiction of the steps or activities that

constitute a process
• ISO standard: ISO 5807
• Specifies the standard flowchart symbols for
information processing
• International Organization for Standardization (ISO)

“Graphical representation of the definition, analysis, or method of

solution of a problem in which symbols are used to represent
operations, data, flow, equipment, etc.”1

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 Flowchart

• Constructed from standard symbols

• Used to communicate processes
• Functionality that is important is the standard shapes
available
• “Connectors” latch to the shapes
• Stay attached until you detach them
• Connectors facilitate editing the flowchart

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 Flowchart Symbols 5

terminal

process

decision

document

connector

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 ISO 5807 section 9.2.1
Basic Process Symbol5

Sign-in at front
desk
“This symbol represents any kind of
processing function, for example,
Confirm Mark patient executing a defined operation or group
insurance as arrived of operations resulting in a change in
value, form or location of information, or
in the determination of which one of
Pull chart several flow directions is to be
followed.”

Escort to exam
room

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 ISO 5807 section 9.2.2.4
Decision

“This symbol represents a decision or

Drug switching type function having a single
Susceptibility
Test entry but where there may be a number of
alternative exits, one and only one of which
may be activated following the evaluation
of conditions defined within the symbol.
The appropriate results of the evaluation
No
Susceptible
Yes may be written adjacent to the lines
representing the paths.”5 Decision symbols
can show nominal decisions (yes / no), or
Altered Standard decisions with multiple possible outcomes.
Prescription Prescription

Begin or Example:
Change
Treatment
Decision symbol use

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 ISO 5807 section 9.4.2
Terminator
“This symbol represents an exit to, or an
entry from, the outside environment, for
Example: Terminator symbol use example, start or end of a program flow,
external use and origin or destination of
data.”

Patient arrives

Sign-in at front
desk

Confirm Mark patient Confirm

insurance As arrived Contact info.

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 Flowchart Example

Examine the flowchart

closely. Take a few
minutes and list the
symbols that are correctly
and incorrectly used
according to the flowchart
symbols on the previous
slide.

Public domain image obtained from http://commons.wikimedia.org/wiki 6

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 Example: Patient Intake
A patient arrives at the healthcare setting/clinic and is signed in by the
receptionist. The receptionist enters the patient into a visit system as present
and confirms the contact and insurance information with the patient. At this
point the patient is ready to be seen by the nurse who will conduct the initial
examination and interview with the patient. The nurse pulls the chart from the
filing stacks and calls the patient to the exam area and escorts the patient to
the exam room, interviews the patient regarding symptoms and/or complaints
and records into the Nurses/Progress notes, and takes and records vital signs
in progress notes. She/he then alerts the Physician that the patient is ready
to be seen. Subsequently, the Physician examines the patient and records
findings in the progress notes, determines if a prescription, procedure, lab
work or a referral is required and completes the necessary paperwork if
applicable. The Physician provides any additional instructions to the patient
and concludes the visit. Finally, the Physician provides the patient chart to
the office staff for refiling and the office staff refiles the patient chart. Also,
the patient pays their co-pay and concludes the office visit.

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 Patient Intake and Clinic Visit
1. Patient arrives at the clinic, signs-in and checks-in with the front desk.
2. Receptionist enters the patient into the visit system as present and
confirms the contact and insurance information with the patient.
3. The nurse pulls the chart from the filing stacks and calls the patient to
the exam area and escorts the patient to the exam room.
4. The nurse interviews the patient regarding symptoms and/or
complaints and records into the Nurses/Progress notes.
5. Nurse takes and records vital signs in progress notes and alerts the
Physician that the patient is ready to be seen.
6. The Physician examines the patient and records findings in the
progress notes.
7. The Physician determines if a prescription, procedure, lab work or a
referral is required and completes the necessary paperwork.
8. The Physician provides any additional instructions to the patient and
concludes the visit.
9. The Physician provides the patient chart to the office staff for refiling.
10. The office staff refiles the patient chart.
11. The patient pays their co-pay and concludes the office visit.

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 Flowchart
Patient arrives

Sign-in at front
desk

Confirm Mark patient Confirm

insurance as arrived contact info.

Pull chart

Escort to exam
room

Record chief
complaint, vitals

Notify provider
1
Patient ready
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 Examine
1 Patient

Order
Write order
Req?

Add Progress
Notes to
Patient Chart

File
Charts

End

Health IT Workforce Curriculum

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 Decision With Multiple Outcomes
This particular example is part of a larger chart. Note the line entering from the left.

Health IT Workforce Curriculum

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 ISO 5807 Section 9.1.2.45
Document

Example document symbol use

Review “This symbol represents human readable

A patient data, the medium being, for example,
charts printed output, an OCR [optical character
recognition] or MICR [magnetic ink
character recognition] document,
microfilm, tally roll, data entry forms.”
File
Charts

End

Health IT Workforce Curriculum

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 Manual input versus manual
operation

ISO 5807 section 9.1.2.5 Manual input

“This symbol represents data, the medium being of
any type where the information is entered manually at
the time of processing, for example, on-line keyboard,
switch settings, push buttons, light pen, bar-code
wand.”
Symbols that have a
meaning

ISO 5807 section 9.2.2.2 Manual operation

“This symbol represents any process performed by a
human being.”

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 Example: Manual Operation
and Manual Input

Billing form
arrives at
receptionist

Locate Claim
patient Form
in system

Keyboard Form for patient

entry of visit appears
patient form

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 Data Symbols

ISO 5807 section 9.1.1.1 Data

“This symbol represents data, the
medium being unspecified.”

ISO 5807 section 9.1.1.2 Stored

data “This symbol represents stored
data in a form suitable for processing, the
medium being unspecified.”

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 ISO 5807 section 9.1.2.8
Display
“This symbol represents data, the medium being
Display example
of any type where the information is displayed for
human use, for example, video screens, on-line
Patient arrives indicators.” The display symbol is shaped like
the traditional cathode ray tube (CRT) computer
monitor viewed from the side.5
Receptionist
checks
Patient in

Receptionist
Form for Patient
locates
visit appears
Patient in EHR

Keyboard entry This would be the front

of the computer screen
of patient
information
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 ISO section 9.4.1 Connector
“This symbol represents an exit to, or an entry from, another part of the same flowchart,
and is used to break a line, and to continue it elsewhere. The corresponding connector
symbols shall contain the same unique identification.”

Escort to exam
room Example: Connector use.
Above the line is the first page of a
Record chief document. Below the line is from the
complaint, vitals second page of the document.
Notify provider
1
Patient ready
Page 1
Examine Page 2
1
Patient

Order
Write order
Req?
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 Data Symbol Example

Patient logged

Data collected during

Record from
referring physician Patient visit

Entry operator locates Form for Patient

Patient in system visit appears

Keyboard entry of
patient form

database

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 Delay

The symbol used to represent a delay in a process looks like a

delay “bullet”. Although not listed in ISO 5807, this symbol is
commonly used because in logic diagrams, it represents an
“and gate”. An “and gate” denotes that two or more things
(thing 1 AND thing 2, two inputs) have to happen before
proceeding.

Two parallel lines are used to denote that things above

them must be done before things below them can be
done. “Processes C, D and E cannot commence until
process A has been completed; similarly process F
should await completion of B, C and D; but process C
may start and/or end before process D has started
and/or ended respectively.” ISO 5807

Diagram from ISO 5807

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 Non-Symbol Flowcharting
Standards
This section covers:
• Use of text descriptions
• Detail level
• Flow direction
• Lines

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 Text Descriptions
Text descriptions are done using “annotations” aka “call-outs.” This keeps the
text in the box to a minimum so the chart is more readable. Lengthy text
descriptions can be referenced to another page or footnote if necessary.

If text descriptions refer to more than one box in a flowchart, a dotted line can be
drawn around the steps that the text describes or refers to.
Data collected
during
Patient visit

Entry operator
locates patient
in system

Keyboard entry of
patient form
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 Detail Level
• Items shown on the same diagram should be at the same
detail level
• For example, in the diagram presented in slide 24, each
box represents one of the main components
– This is a high level view of the process
• The diagram in the following slide is an example of
combining items at different detail levels on the same
diagram
– Combining items at different detail levels can cause confusion

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 Detail Level
Identify data Define Measure Record Process Analyze
to be collected

Report Report
(status) (results)

Identify data Ready to Analyze Report

Define Measure Record
to be collected process (results)

Check Validity, Code Render data in

completeness & Data electronic form
accuracy

E Prescribe
Valid
Complete

accurate?
Processing
complete

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 Flow
Flowcharts should “read” from top to bottom or right to left. Affirmative responses
to yes/no decisions should all be in the same direction. Flow direction for process
steps that show re-work (i.e. queries for data discrepancies going back to sites)
should be opposite of the direction of the progressing process.

Age > 18 yrs. Age > 18 yrs.

Yes Yes

Comp. 2 wk Yes Comp. 2 wk No

Enroll Not Eligible
washout washout

No Yes
Not Eligible
Enroll

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 Flow
Flowcharts should “read” from top to bottom or left and right. Lines should run up
& down or left and right. Do not use diagonal lines.

HIPAA consent HIPAA consent

signed signed

Administer Draw blood

Health Question
Administer Draw blood
Health
Questionnaire

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 Lines
A solid line is used to denote data or process flow.
Arrows represent the direction of the flow.

A dashed line is used to denote an alternate path.

Arrows represent the direction of the flow.

A jagged line is used to denote data transfer by a

telecommunications link. Arrows represent the
direction of the flow.

Two parallel lines denote a synchronization

between two parallel processes. i.e. that the
things above it have to happen and all come to the
denoted state before the things below it can occur.
There are no arrows on synchronization lines.
All lines that represent flow based on decisions should be labeled.
Lines should run up & down or left and right. Do not use diagonal lines.
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 References
1. Wickens CD, Hollands JG. Engineering Psychology and Human Performance. 3rd ed.
Upper Saddle River, NJ: Prentice Hall, Inc; 1999.
2. The American Heritage® Dictionary of the English Language, Fourth Edition copyright
©2000 by Houghton Mifflin Company. Published by Houghton Mifflin. Updated in
2009.
3. BusinessDictionary.com, available from
http://www.businessdictionary.com/definition/process-owner.html, Copyright©2010
4. "flowchart." Merriam-Webster Online Dictionary. 2010. Merriam-Webster Online. 23
June 2010
http://www.merriam-webster.com/dictionary/flowchart
5. ISO/ANSI 5807 Information processing - Documentation symbols and conventions for
data, program and system flowcharts, program network charts and system
resources charts. 1985.
6. Juran Joseph M, Gryna Frank M. (eds.) Juran’s Quality Control Handbook. McGraw-
Hill, Inc. New York.
7. Wikipedia contributors. "Flowchart." Wikipedia, The Free Encyclopedia. Wikipedia, The
Free Encyclopedia, 22 Jun. 2010. Web. 23 Jun. 2010.
8. Public Health Institute, 2006. Taking Care of Business: A Collaboration to Define
Local Health Department Business Processes. Decatur, GA: Public Health
Informatics Institute. Available online at www.phii.org.

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