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Keywords:

  • literature review;
  • nursing diagnosis;
  • nursing documentation;
  • nursing process

Aim.  To identify what determinants influence the prevalence and accuracy of nursing diagnosis documentation in clinical practice.

Background.  Nursing diagnoses guide and direct nursing care. They are the foundation for goal setting and provide the basis for interventions. The literature mentions several factors that influences nurses’ documentation of diagnoses, such as a nurse’s level of education, patient’s condition and the ward environment.

Design.  Systematic review.

Method.  MEDLINE and CINAHL databases were searched using the following headings and keywords: nursing diagnosis, nursing documentation, hospitals, influence, utilisation, quality, implementation and accuracy. The search was limited to articles published between 1995–October 2009. Studies were only selected if they were written in English and were primary studies addressing factors that influence nursing diagnosis documentation.

Results.  In total, 24 studies were included. Four domains of factors that influence the prevalence and accuracy of diagnoses documentation were found: (1) the nurse as a diagnostician, (2) diagnostic education and resources, (3) complexity of a patient’s situation and (4) hospital policy and environment.

Conclusion.  General factors, which influence decision-making, and nursing documentation and specific factors, which influence the prevalence and accuracy of nursing diagnoses documentation, need to be distinguished. To support nurses in documenting their diagnoses accurately, we recommend taking a comprehensive perspective on factors that influence diagnoses documentation. A conceptual model of determinants that influence nursing diagnoses documentation, as presented in this study, may be helpful as a reference for nurse managers and nurse educators.

Relevance to clinical practice.  This review gives hospital management an overview of determinants for possible quality improvements in nursing diagnoses documentation that needs to be undertaken in clinical practice.