Creating ISO/ANSI Flowcharts

This is Process Representation Unit 2 of 6.
(Previous - Process Representation Unit 1 of 6: Interpreting and Creating Process Diagrams: Introduction)

Welcome to the ISO 5807 Flowcharting subunit.  This is the second subunit of the Process Mapping Unit.

Unit Objectives

  • 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

Remember in a previous unit 2 we introduced the concept of ISO 5807 flowcharting notation to diagram a process. Here, we will provide further details about the ISO 5807 symbols and conventions. We will describe the standard diagramming symbols and conventions so that you will become familiar with standard flowchart symbols and be able to read a flowchart and understand the data or process flow being communicated.

We will also give examples to help you understand how to use standard symbols to document and communicate a process and then be able to create your own process diagrams using standard flowchart form.

Methods for Diagramming Processes

Also, remember that each of the methods for diagramming a process has its own set of capabilities. With ISO 5807 flowcharts a process analyst is able to represent the process steps, any information transformations that occur or should occur, the order or sequence of the steps involved in the process, and the roles of the persons completing the steps in the process. The flowchart is a useful tool in mapping the workflow processes in the clinical health care system.

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

A flowchart is a graphic depiction of the steps or activities that constitute a process.

The International Standards Organization (ISO) defines flowchart as a “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  Many organizations require the documentation of dataflow or process flow. Some organizations require a flowchart to accompany every Standard Operating Procedure (SOP). Organizations also use flowcharts to document and communicate the data flow and or process flow for a research project.

  • 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

Flowcharts are constructed from standard symbols. It is important that standard symbols be used because flowcharts are used to communicate processes. When people see a specific symbol in a chart, they understand a specific meaning. Thus, to read, use, and create flowcharts knowing the meaning of the standard symbols is important. There is an ISO standard, ISO 5807, that specifies the standard flowchart symbols for information processing. Excerpts in this set of slides are taken directly from the ISO standard.

Many software applications have flowcharting functionality. Some of these are Microsoft Word, Microsoft PowerPoint, and Visio. The functionality that is important to flowcharting is that the standard shapes are available and that there are “connectors” that latch to the shapes and stay attached until you detach them.  This facilitates editing the flowchart.

Flowchart Symbols

The terminal symbol is a rounded rectangle which identifies the beginning or end of a process or origin and destination of data.

The process symbol is a rectangle which designates an activity. Within the rectangle is a brief description of that activity.

The decision symbol is a diamond which designates a decision point from which the process branches into two or more paths. The path taken depends on the answer to the question which appears within the diamond. Each path is labeled to correspond to an answer to the question.

The document symbol is a human-readable document pertinent to the process.

The flow line represents a process path which connects process elements. The arrowhead indicates the direction of the flow.

The connector is a circle which is used to indicate a continuation of the flow diagram.

ISO 5807 section 9.2.1 - Basic Process Symbol

The Basic Process “symbol represents any kind of processing function, for example, executing a defined operation or group of operations resulting in a change in value, form or location of information, or in the determination of which one of several flow directions is to be followed.”

In this example, the basic process symbol represents the following:

  • Patient signs-in and checks-in with the front desk,
  • Receptionist enters the patient into the visit system as present and confirms the insurance information with the patient
  • The nurse pulls the chart from the filing stacks and
  • Escorts the patient to the exam room.
ISO 5807 section 9.2.2.4 - Decision

The decision, or diamond, “symbol represents a decision or switching type function having a single 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 may be written adjacent to the lines representing the paths.”

Decision symbols can show nominal decisions (yes / no), or decisions with multiple possible outcomes.

In this example, the patient is given a drug susceptibility test and a decision is made as to the appropriate type of prescription to write based on the test results. As you can clearly see, the actions are different for the patients who are susceptible and the patients who are not.

This decision in the process is clearly represented with the ISO 5807 symbols.

ISO 5807 section 9.4.2 - Terminator

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

Here the Terminator symbol is used to represent the entry of the patient into the process (health care workflow setting).

Flowchart Example

Correct symbols are used for the decision boxes and the connectors.

Incorrect symbol use is

  1. a matter of which notation one is following, and

  2. how formal or conformant to any one notation one wants to be, i.e., correctness with respect to notation is a relative matter.

Comparing the flowchart on this slide to the list of symbols on  slide 6, we see that the rounded-corner rectangle used as a terminator should be a different shape, one with parallel lines on the top and bottom and half-circle curvature on the left and right sides. The arrow heads should be shaded or filled in rather than open.

Example: Patient Intake

Next we have an example of a defined health care process flow. We will use this scenario to demonstrate representing a process in pictorial form, i.e. in a process flow chart. Read this scenario and list the process steps.
Patient Intake Example:

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 her co-pay and concludes the office visit.

Pause now and list the process steps now.  After you resume, we will go over the steps so that you can see how you did.  Pause now.

Patient Intake and Clinic Visit

The scenario will first be broken down into discrete steps.  The tasks are placed in sequential order. 

Read through these steps, and determine if they matched the ones that you listed.

The steps are:

  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.

Flowchart - Patient Intake and Clinic Visit

Read the sequence of the tasks.

  • Patient arrives
  • Sign-in at front desk
  • Mark patient as arrived
  • Confirm insurance
  • Confirm contact info.
  • Pull chart
  • Escort to exam room
  • Record chief complaint, vitals
  • Notify provider Patient ready
  • Go to 1

Compare the flowchart to the list of steps.  Remember the connector symbol. This flowchart continues below.

Read the sequence of the slides.

  • Come from 1
  • Examine Patient
  • Order Req?
  • Write Order
  • Add Progress Notes to Patient Chart
  • File Charts
  • End

Note that the connector with a “1” connects the process across the two slides.

Decision With Multiple Outcomes

Process flow diagrams can become quite complex.  The above example is taken from a hospital setting where there are multiple decisions to be made and multiple actions based on these decisions. This complexity is found in most health care settings.

In this In-patient hospitalization example we will walk through key decisions and actions as displayed in the above illustration..

  1. A patient is admitted to the hospital and placed in an examination room
    1. The Admission Summary is completed
  2. Various observations per the hospital standards are obtained.  These can include:
    1. Vital signs, temperature
    2. Continuous 12-lead monitoring
    3. Cardiac Enzymes
    4. Distal pulse
    5. Noting of wounds, pain, and/or other symptoms
    6. Presence of a hematoma or clotting time if there is bleeding
  3. Medication is administered, and
  4. Continuations of the medical assessment which will be determined by preliminary findings. Examples are:
    1. If there is chest pain, then collect duration of hospital stay related to chest pain
    2. If the patient displays oozing of hematoma, then evaluate for surgical repair of puncture site and prepare for the Operation Room
    3. If the patient is improving, then transfer to step-down facility and plan for the patient to be discharged
    4. If the patient is not improving, then manage medically by continuing various observations per hospital standards and continuing medical assessments
    5. If the patient has a planned Coronary Artery Bypass Graft (CABG) which is expected, then prepare for the Operation Room
    6. If the patient has complications from a procedure, either expected or unexpected in this representation, the staff will prepare for the Operation Room.
  5. Finally, a discharge summary will need to be prepared.

ISO 5807 Section 9.1.2.45 - Document

“This symbol (a rectangle with the bottom long side is curved such that the left side is lower) represents human-readable data, the medium being, for example, printed output, an OCR [optical character recognition] or MICR [magnetic ink character recognition] document, microfilm, tally roll, data entry forms.”

Here the staff member reviews the patient’s charts and files them. The file is represented by a rectangle.


Manual Input versus Manual Operation

According to ISO 5807 section 9.1.2.5, the symbol for manual input is a quadrilateral with two parallel sides, two 90° angles, one obtuse angle and one acute angle.  “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.”

According to ISO 5807 section 9.2.2.2, the symbol for a manual operation is an isosceles trapezoid (a quadrilateral with two parallel sides and the sides that aren't parallel are equal in length and both angles coming from a parallel side are equal).  “This symbol represents any process performed by a human being.”

Example: Manual Operation and Manual Input

In this example, the manual operation of receiving the forms and manual input of keyboard entry of data are represented.
The example is as follows:

Billing form arrives at receptionist 
→ Locate patient in system
→ Keyboard entry of patient form
→ Form for patient visit appears

Claim form → Form for patient visit appears

 

Data Symbols

According to ISO 5807 section 9.1.1.1, the symbol for Data is a parallelogram (opposite sides are parallel and equal in length, and opposite angles are equal).  “This symbol represents data, the medium being unspecified.”

According to ISO 5807 section 9.1.1.2, the symbol for stored data is a four-sided figure with two-parallel sides, one rounded concave end and one rounded convex end.  “This symbol represents stored data in a form suitable for processing, the medium being unspecified.”

ISO 5807 section 9.1.2.8 - Display

“This symbol represents data, the medium being of any type where the information is displayed for human use, for example, video screens, on-line indicators.”5

The display symbol is shaped like the traditional cathode ray tube (CRT) computer monitor viewed from the side.
The flowchart example shows the following:

  • Patient  arrives
  • Receptionist checks Patient in
  • Receptionist locates Patient in EHR
  • Form for Patient visit appears (on computer screen)
  • Keyboard entry of patient information

ISO section 9.4.1 - Connector

According to ISO section 9.4.1, the symbol for a Connector is a circle with a number in it.  “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.”

Example

  • Page 1 of flowchart:
    • Escort to exam room → Record chief complaint, vitals → Notify provider Patient ready → Go to the next page and start at the circle with a 1 in it.
  • Page 2:
    • Start at the circle with a 2 in it → Examine Patient → Order Req? → Write order

Note that the connector with a “1” connects the process across pages one and two.

Data Symbol Example

Above is a Data Symbol example.

  1. Patient logged → Data collected during Patient visit and Record from referring physician

  2. Data collected during Patient visit → Entry operator locates Patient in system → Keyboard entry of patient form and Form for Patient visit appears

  3. Keyboard entry of patient form → database
  4. Record from referring physician → database In this example data are represented in two distinct ways.

Note that the generic data symbol is used for data from the referring physician. It  does not specify medium, such as disc or electronic file transfer. Use of the stored data symbol for the office database also signifies data, however, the symbol is specific to stored data. The vertical cylinder could have also been used.

Delay

The symbols used to represent a delay in a process are given here. The “bullet”, although not listed in ISO 5807, 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

Non-Symbol Flowcharting Standards

In this section, we will cover non-symbol flowcharting. 

Non-symbol flowcharting includes:

  • The use of text descriptions,
  • indication of detail level,
  • flow direction, and
  • lines.

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.

It is often important to include text descriptions in a process representation.  This is 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.

Detail Level

While flowcharts can be used to represent different levels of process detail 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.

Detail Level

Here are two different flowcharts for E Prescribing:

The top flowchart example is as follows:
Identify data to be collected → Define → Measure → Record → Process → Report (status) or Analyze
Analyze → Report (results)

The bottom flowchart example is as follows:
Identify data to be collected → Define → Measure → Record → Ready to process → Check Validity, completeness and accuracy or Code Data or Render data in electronic form or Analyze
Check Validity, completeness and accuracy, Code Data and Render data in electronic form → Valid Complete accurate? → Processing complete
If processing is not complete → Check Validity, completeness & accuracy
Analyze → Report (results)

Note the different level of detail in the second flowchart which includes the data processing steps.  This might be better in a second flowchart. 

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.

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

Note this is left and right; not left to right.

Lines

There are multiple ways to connect process and data flow.

  • 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 (zig-zag) 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 and down or left and right.  Do not use diagonal lines

References

These references were used to prepare the slides in this unit.

  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

(Next - Process Representation Unit 3 of 6: Creating Data Flow Diagrams in Yourdon Notation)

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