title: What factors influence the prevalence and accuracy of nursing diagnoses documentation in clinical practice? A systematic literature review.
abstract: OBJECTIVE
  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.
  
  
  METHODS
  Systematic review.
  
  
  METHODS
  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.
  
  
  CONCLUSIONS
  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.
  
  
  CONCLUSIONS
  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.
authors.affiliation: Hanze University of Applied Sciences, Groningen, The Netherlands. w.paans@pl.hanze.nl
authors.forename: Wolter
authors.initials: W
authors.lastname: Paans
authors.forename: Roos Mb
authors.initials: RM
authors.lastname: Nieweg
authors.forename: Cees P
authors.initials: CP
authors.lastname: van der Schans
authors.forename: Walter
authors.initials: W
authors.lastname: Sermeus
mesh_terms: D004282:Documentation; D009733:Nursing Diagnosis