flowchart TD
%% Patient Swimlane
subgraph Patient["👤 PATIENT"]
direction LR
P1["Patient Arrives
Presents to clinic/hospital"]:::patientNode P2["Provides Information
Demographics, insurance,
chief complaint"]:::patientNode P3["Undergoes Care
Examination, tests,
procedures, treatments"]:::patientNode P4["Receives Instructions
Discharge instructions,
prescriptions, follow-ups"]:::patientNode P5["Receives Bill/EOB
Explanation of Benefits
charges and coverage"]:::patientNode end %% Clinical Staff Swimlane subgraph Clinical["🏥 CLINICAL STAFF"] direction LR C1["Registration
Verify identity, check
insurance, collect copay"]:::clinicalNode C2["Triage/Vitals
Record vitals, chief
complaint, meds, allergies"]:::clinicalNode C3["Provider Assessment
History, physical exam,
differential diagnosis"]:::clinicalNode D1{"Admit to
Hospital?"}:::decisionNode C4["Order Entry
Labs, imaging,
medications, procedures"]:::clinicalNode C5["Results Review
Interpret test results,
revise diagnosis"]:::clinicalNode C6["Documentation
Clinical notes, diagnosis
codes, procedure codes"]:::clinicalNode C7["Discharge/Follow-up
Prescriptions, referrals,
next appointment"]:::clinicalNode end %% Clinical Systems Swimlane subgraph Systems["💻 CLINICAL SYSTEMS"] direction LR S1["EHR: Create Encounter
New encounter record
with patient context"]:::systemNode D2{"Eligibility
Active?"}:::decisionNode S2["CPOE: Receive Orders
Computerized Provider
Order Entry"]:::systemNode S3["Lab/Imaging: Perform
Diagnostic services
execute tests"]:::systemNode S4["Results Interface
Test results via
HL7/FHIR"]:::systemNode S5["EHR: Finalization
Provider signs note,
triggers billing"]:::systemNode end %% Administrative Systems Swimlane subgraph Admin["💰 ADMINISTRATIVE SYSTEMS"] direction LR A1["Eligibility Check
Real-time verification
via clearinghouse"]:::financeNode A2["Charge Capture
Extract billable services
from documentation"]:::financeNode D3{"Coding
Complete?"}:::decisionNode A3["Medical Coding
Assign ICD, CPT,
HCPCS codes"]:::financeNode A4["Claim Generation
Create CMS-1500
or UB-04 claim"]:::financeNode D4{"Claim
Accepted?"}:::decisionNode A5["Claim Submission
EDI 837 transaction
to payer"]:::financeNode A6["Adjudication Wait
Payer reviews claim,
determines payment"]:::financeNode A7["Payment Posting
Record payment,
adjustments, patient balance"]:::financeNode end %% Flow Connections - Sequential workflow P1 --> C1 C1 --> P2 P2 --> A1 A1 --> D2 D2 -->|Yes| S1 D2 -->|No| C1 S1 --> C2 C2 --> C3 C3 --> D1 D1 -->|No - Outpatient| C4 D1 -->|Yes - Inpatient| P3 C4 --> S2 S2 --> S3 S3 --> P3 S3 --> S4 S4 --> C5 C5 --> C6 C6 --> S5 S5 --> A2 A2 --> D3 D3 -->|No| A3 A3 --> D3 D3 -->|Yes| A4 A4 --> A5 A5 --> D4 D4 -->|No - Fix Errors| A3 D4 -->|Yes| A6 C7 --> P4 C6 --> C7 A6 --> A7 A7 --> P5 %% Styling Classes classDef patientNode fill:#4A90E2,stroke:#2E5C8A,stroke-width:3px,color:#fff,font-size:16px classDef clinicalNode fill:#7ED321,stroke:#5A9B19,stroke-width:3px,color:#333,font-size:16px classDef systemNode fill:#9013FE,stroke:#6B0FBF,stroke-width:3px,color:#fff,font-size:16px classDef financeNode fill:#FF8C42,stroke:#CC6F35,stroke-width:3px,color:#fff,font-size:16px classDef decisionNode fill:#FFD700,stroke:#CCA300,stroke-width:3px,color:#333,font-size:16px linkStyle default stroke:#666,stroke-width:2px,font-size:14px
Presents to clinic/hospital"]:::patientNode P2["Provides Information
Demographics, insurance,
chief complaint"]:::patientNode P3["Undergoes Care
Examination, tests,
procedures, treatments"]:::patientNode P4["Receives Instructions
Discharge instructions,
prescriptions, follow-ups"]:::patientNode P5["Receives Bill/EOB
Explanation of Benefits
charges and coverage"]:::patientNode end %% Clinical Staff Swimlane subgraph Clinical["🏥 CLINICAL STAFF"] direction LR C1["Registration
Verify identity, check
insurance, collect copay"]:::clinicalNode C2["Triage/Vitals
Record vitals, chief
complaint, meds, allergies"]:::clinicalNode C3["Provider Assessment
History, physical exam,
differential diagnosis"]:::clinicalNode D1{"Admit to
Hospital?"}:::decisionNode C4["Order Entry
Labs, imaging,
medications, procedures"]:::clinicalNode C5["Results Review
Interpret test results,
revise diagnosis"]:::clinicalNode C6["Documentation
Clinical notes, diagnosis
codes, procedure codes"]:::clinicalNode C7["Discharge/Follow-up
Prescriptions, referrals,
next appointment"]:::clinicalNode end %% Clinical Systems Swimlane subgraph Systems["💻 CLINICAL SYSTEMS"] direction LR S1["EHR: Create Encounter
New encounter record
with patient context"]:::systemNode D2{"Eligibility
Active?"}:::decisionNode S2["CPOE: Receive Orders
Computerized Provider
Order Entry"]:::systemNode S3["Lab/Imaging: Perform
Diagnostic services
execute tests"]:::systemNode S4["Results Interface
Test results via
HL7/FHIR"]:::systemNode S5["EHR: Finalization
Provider signs note,
triggers billing"]:::systemNode end %% Administrative Systems Swimlane subgraph Admin["💰 ADMINISTRATIVE SYSTEMS"] direction LR A1["Eligibility Check
Real-time verification
via clearinghouse"]:::financeNode A2["Charge Capture
Extract billable services
from documentation"]:::financeNode D3{"Coding
Complete?"}:::decisionNode A3["Medical Coding
Assign ICD, CPT,
HCPCS codes"]:::financeNode A4["Claim Generation
Create CMS-1500
or UB-04 claim"]:::financeNode D4{"Claim
Accepted?"}:::decisionNode A5["Claim Submission
EDI 837 transaction
to payer"]:::financeNode A6["Adjudication Wait
Payer reviews claim,
determines payment"]:::financeNode A7["Payment Posting
Record payment,
adjustments, patient balance"]:::financeNode end %% Flow Connections - Sequential workflow P1 --> C1 C1 --> P2 P2 --> A1 A1 --> D2 D2 -->|Yes| S1 D2 -->|No| C1 S1 --> C2 C2 --> C3 C3 --> D1 D1 -->|No - Outpatient| C4 D1 -->|Yes - Inpatient| P3 C4 --> S2 S2 --> S3 S3 --> P3 S3 --> S4 S4 --> C5 C5 --> C6 C6 --> S5 S5 --> A2 A2 --> D3 D3 -->|No| A3 A3 --> D3 D3 -->|Yes| A4 A4 --> A5 A5 --> D4 D4 -->|No - Fix Errors| A3 D4 -->|Yes| A6 C7 --> P4 C6 --> C7 A6 --> A7 A7 --> P5 %% Styling Classes classDef patientNode fill:#4A90E2,stroke:#2E5C8A,stroke-width:3px,color:#fff,font-size:16px classDef clinicalNode fill:#7ED321,stroke:#5A9B19,stroke-width:3px,color:#333,font-size:16px classDef systemNode fill:#9013FE,stroke:#6B0FBF,stroke-width:3px,color:#fff,font-size:16px classDef financeNode fill:#FF8C42,stroke:#CC6F35,stroke-width:3px,color:#fff,font-size:16px classDef decisionNode fill:#FFD700,stroke:#CCA300,stroke-width:3px,color:#333,font-size:16px linkStyle default stroke:#666,stroke-width:2px,font-size:14px
About This Diagram
This interactive workflow diagram illustrates the complete patient encounter journey from arrival through final billing. The diagram uses four swimlanes to show parallel activities across different roles and systems:
- 👤 Patient Lane (Blue): The patient's experience and touchpoints throughout the encounter
- 🏥 Clinical Staff Lane (Green): Registration, nursing, and physician activities including assessment, ordering, and documentation
- 💻 Clinical Systems Lane (Purple): EHR, CPOE, laboratory, and imaging system processes
- 💰 Administrative Systems Lane (Orange): Billing, coding, claims, and payment workflows
Key Decision Points
- Eligibility Check: Verifies active insurance coverage before creating encounter
- Admit to Hospital: Determines outpatient vs. inpatient care pathway
- Coding Complete: Ensures proper diagnosis and procedure codes before claim submission
- Claim Accepted: Validates claim data and triggers payment processing or error correction
Data Standards Used
- HL7 v2/FHIR: Clinical data exchange between EHR, lab, and imaging systems
- X12 EDI 837: Electronic claim submission format
- ICD-10: Diagnosis codes
- CPT/HCPCS: Procedure and service codes
- CMS-1500/UB-04: Standard claim forms
Typical Timeframes
- Registration to Provider Assessment: 15-30 minutes
- Assessment to Test Results: 1-4 hours (varies by test complexity)
- Documentation to Claim Submission: 1-7 days
- Claim Submission to Payment: 14-45 days
Common Pain Points
- Insurance Eligibility: Real-time verification failures cause registration delays
- Results Delay: Manual result entry or interface failures slow clinical decisions
- Coding Accuracy: Insufficient documentation leads to claim denials and rework
- Claim Rejections: Data quality issues require resubmission, delaying payment 30-60 days