Smith A R, Chang B L
Nurs Diagn. 1996 Jan-Mar;7(1):9-18.
This study examined the reliability of nursing diagnoses identified from the medical records of 100 patients hospitalized for HIV disease on a 22-bed designated unit at a large metropolitan teaching hospital in Los Angeles. The diagnoses were identified in two ways: (a) staff nurses identified 16 different nursing diagnoses using preprinted care plans found in the medical records, with 2 to 9 problems per patient (M = 4.8, SD = 1.6) and (b) the nurse researcher-identified 45 different nursing diagnoses derived from defining characteristics documented in the medical records, with 1 to 9 identified problems per patient (M = 3.3, SD = 1.8). The most frequent problems identified were the same as those addressed in the clinical literature: pain, respiratory problems, nutritional deficits, and psychosocial concerns. The results of this study raise concerns about the limitations of nursing diagnosis research using existent data bases and the use of preprinted care plans.