Reliability of nursing diagnoses documented in a computerized nursing information system

PURPOSE. To assess the reliability of the nursing diagnosis impaired physical mobility as documented by staff nurses using a computerized nursing information system (NIS). METHODS. A convenience sample of records (N = 30) from an adult rehabilitation service in the Midwest was examined. Two master's-level graduate students retrospectively examined clinical records to determine if assessment data were present that met the operational definitions for the defining characteristics and related factors o f impaired physical mobility. FINDINGS. Impaired physical mobility was diagnosed in 23 records. Interrater agreement on the presence or absence of defining characteristics ranged from 52% to 100%; agreement for the presence or absence of related factors ranged from 57% to 100% . CONCLUSIONS. The reliability of impaired physical mobility for an adult rehabilitation patient population as diagnosed by staff RNs and documented in a computerized NIS was supported.