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Creating a PRISMA flow diagram

Choosing a PRISMA Flow Diagram

In PRISMA 2020, there are now expanded options depending on where you search and whether you are updating a review. Version 1 of PRISMA 2020 includes databases and clinical trial or preprint registers.  Version 2 includes additional sections for elaborating on other sources that you have located, such as searches on websites (like Google Scholar) or in citation lists. Both versions are available for new and updated reviews from the Equator Network's PRISMA Flow Diagram page.

Templates for New Systematic Reviews
  • PRISMA 2020 V1 - Databases and Registers
    • The PRISMA diagram for Databases and Registers follows the same format as the previous 2009 PRISMA diagram.
  • PRISMA 2020 V2 - Databases, Registers, and Other Sources
    • The PRISMA diagram for Databases, Registers, and Other Sources has an additional column on the right side of the diagram for reporting of other searches and results.

Step-by-step: PRISMA 2020 Flow Diagram

Step 1: Preparation 

To complete the the PRISMA diagram, save a copy of the diagram & checklist to use alongside your searches. It can be downloaded from the PRISMA website. I would recommend printing the diagram off and writing on it as you complete the PRISMA process. On the checklist, pay special attention to sections #6 to #8. In addition, before you begin your search you should read the PRISMA-S information & checklist.

In addition, you may find the following YouTube Video created by MD Anderson Research Library helpful. If you would like to use EndNote, here is a great video on how to integrate PRISMA with EndNote (more information on Endnote can be found here).

Step 2: Doing the Database Search 

Run the search for each database individually, including ALL your search terms, any MeSH or other subject headings, truncation (like hemipleg*), and/or wildcards (like sul?ur). Apply all your limits (such as years of search, English language only, and so on). Once all search terms have been combined and you have applied all relevant limits, you should have a final number of records or articles for each database. Enter this information in the top left box of the PRISMA flow chart. You should also keep track your searches using the PRISMA-S extension. You should add the total number of combined results from all databases (including duplicates) after the equal sign where it says Databases (n=). Many researchers also add notations in the box for the number of results from each database search, for example, Medline with Fulltext (n=335), Cinahl Plus with Fulltext (n= 600), and so on. FYI Google Scholar should be documented following the next section about Documenting Other Sources. If you search trial registers, such as ClinicalTrials.gov, CENTRAL, ICTRP, or others, you should enter that number after the equal sign in Registers (n=). You should also keep track of your searches using the PRISMA-S extension. Search strategies for all databases should be maintained on a document as they need to be reported in the final systematic/scoping review.

NOTE: Some citation managers automatically remove duplicates with each file you import.  Be sure to capture the number of articles from your database searches before any duplicates are removed.

Records identified from databases or registers

Step 3: Remove All Duplicates 

To avoid reviewing duplicate articles, you need to remove any articles that appear more than once in your results. I have created a page on how to Deduplicate your search results - read over this to learn how to do it. Enter the number of records removed as duplicates in the second box on your PRISMA template.  If you are using automation tools to help evaluate the relevance of citations in your results, you would also enter that number here. You can use Endnote to automatically deduplicate your results - For more information see this YouTube video from JCU Library.

Records removed before screening: duplicates, automation tool exclusions, or other reasons

NOTE: If you are using Covidence to screen your articles, you can copy the numbers from the PRISMA diagram in your Covidence review into the boxes mentioned below.  Covidence does not include the number of results from each database, so you will need to keep track of that number yourself. APU does not have a subscription for this however you can sign up for a free trial here. 

Step 4: Records Screened- Title/Abstract Screening 

The next step is to add the number of articles that you will screen. This should be the number of records identified minus the number from the duplicates removed box.

Number of records screened in Title/Abstract level

Step 5: Records Excluded- Title/Abstract Screening 

You will need to screen the titles and abstracts for articles which are relevant to your research question. Any articles that appear to help you provide an answer to your research question should be included. Record the number of articles excluded through title/abstract screening in the box to the right titled "Records excluded."  You can optionally add exclusion reasons at this level, but they are not required until full text screening.

Records excluded after title & abstract screening

Step 6: Reports Sought for Retrieval 

This is the number of articles you obtain in preparation for full text screening.  Subtract the number of excluded records (Step 5) from the total number screened (Step 4) and this will be your number sought for retrieval.

Reports sought for retrieval

Step 7: Reports Not Retrieved 

List the number of articles for which you are unable to find the full text.  Remember to use Article Finder & Interlibrary Loan to locate articles in which we have a subscription and to request articles from other libraries before automatically excluding them.

Reports not retrived

Step 8: Reports Assessed for Eligibility- Full Text Screening

This should be the number of reports sought for retrieval (Step 6) minus the number of reports not retrieved (Step 7). Review the full text for these articles to assess their eligibility for inclusion in your paper. 

Reports assessed for eligibility

Step 9: Reports Excluded

After reviewing all articles in the full-text screening stage for eligibility, enter the total number of articles you exclude in the box titled "Reports excluded," and then list your reasons for excluding the articles as well as the number of records excluded for each reason.  Examples include wrong setting, wrong patient population, wrong intervention, wrong dosage, etc.  You should only count an excluded article once in your list even if if meets multiple exclusion criteria.

Reports excluded, including reason for exclusion and number

Step 10: Included Studies 

The final step is to subtract the number of records excluded during the eligibility review of full-texts (Step 9) from the total number of articles reviewed for eligibility (Step 8). Enter this number in the box labeled "Studies included in review," combining numbers with your sources from other methods search results in this box if needed.  You have now completed your PRISMA flow diagram, unless you have also performed searches in non-database sources. 

Reports of included studies: "Authors might identify a study that has results appearing in two reports (for example one providing data at three months, another at two years follow-up). In this case, the number of studies included in the review is one, whereas the number of reports of included studies is two. This distinction was introduced in the PRISMA 2020 flow diagram based on our observation that the jump from the number of reports assessed for eligibility to the number of studies included in the review (as was prompted in the original PRISMA flow diagram) sometimes resulted in some reports not being accounted for. For example, we have seen some flow diagrams where the authors report assessing fifty full-text reports for eligibility, excluding forty reports, and including eight studies (failing to indicate that two of the eight studies were published in two reports)" (Rethlefsen & Page, 2021).

Studies included in review

If you have also searched additional sources, such as professional organization websites, cited or citing references, etc., complete the additional steps listed in the following "Documenting Other Sources".

Step 11: Fill in the numbers on the PRISMA app.

This tool allows you to produce a flow diagram for your own review that conforms to the PRISMA2020 Statement. You can provide the numbers in the data entry section of the 'Create flow diagram' tab (click on the button at the top of the page).
 

It also allows you to download an interactive HTML, PDF, PNG version of the plot, alongside several other common formats.

Automatically generate your diagram using the ShinyApps Prisma Flow Diagram

Please remember to cite the tool as:

Haddaway, N. R., Page, M. J., Pritchard, C. C., & McGuinness, L. A. (2022). PRISMA2020: An R package and Shiny app for producing PRISMA 2020-compliant flow diagrams, with interactivity for optimised digital transparency and Open Synthesis Campbell Systematic Reviews, 18, e1230. https://doi.org/10.1002/cl2.1230

Documenting Other Sources

To document other sources search, download the flow diagram template

Complete the boxes documenting your database searches on the left side of the template as outlined in the previous box Step-by-step: PRISMA 2020 Flow Diagram.  Complete the right side of the template, Identification of studies via other methods, using the steps below.

Step 1: Records Identified

If you have identified articles through other sources than databases (such as manual searches through reference lists of articles you have found or search engines like Google Scholar), enter the total number of records from each source type in the box on the top right of the flow diagram.

Records identified from websites, organizations, citation searching, or other methods

Step 2: Reports Sought for Retrieval 

This should be the total number of reports you obtain from other sources. 

Reports sought for retrieval

Step 3: Reports Not Retrieved 

List the number of documents for which you are unable to find the full text.  Remember to use Article Finder and Interlibrary Loan to locate articles in which we have a subscription and to request articles from other libraries before automatically excluding them.

Reports not retrieved

Step 4: Reports Assessed for Eligibility

This should be the number of other source methods reports sought for retrieval (Step 2) minus the number of reports not retrieved (Step 3). Review the full text for these items to assess their eligibility for inclusion in your paper. 

Reports assessed for eligibility (full text)

Step 5: Reports excluded

After reviewing all items in the full-text screening stage for eligibility, enter the total number of articles you exclude in the box titled "Reports Excluded," and then list your reasons for excluding the item as well as the number of items excluded for each reason.  Examples include wrong setting, wrong patient population, wrong intervention, wrong dosage, etc.  You should only count an excluded item once in your list even if if meets multiple exclusion criteria.

Reports excluded, with reasons for exclusion and number

Step 6: Included Studies

The final step is to subtract the number of excluded articles or records during the eligibility review of full-texts from the total number of articles reviewed for eligibility. Enter this number in the box labeled "Studies included in review," combining numbers with your database search results in this box if needed.  You have now completed your PRISMA flow diagram, which you can now include in the results section of your article or assignment. 

Reports of included studies: "Authors might identify a study that has results appearing in two reports (for example one providing data at three months, another at two years follow-up). In this case, the number of studies included in the review is one, whereas the number of reports of included studies is two. This distinction was introduced in the PRISMA 2020 flow diagram based on our observation that the jump from the number of reports assessed for eligibility to the number of studies included in the review (as was prompted in the original PRISMA flow diagram) sometimes resulted in some reports not being accounted for. For example, we have seen some flow diagrams where the authors report assessing fifty full-text reports for eligibility, excluding forty reports, and including eight studies (failing to indicate that two of the eight studies were published in two reports)" (Rethlefsen & Page, 2021).

Studies included in review

Updating a systematic review with PRISMA 2020


PRISMA 2020 templates for updated reviews include a box for the number of studies and reports included in the previous version of the review.If you are updating an existing review, use one of these PRISMA 2020 Updated Review templates, which feature an additional box for the number of studies and reports of studies included in the previous search iterations.

Citing PRISMA 2020

When referring to PRISMA 2020, The Equator Network recommends using journal article citations (such as those in our References below) rather than referring to the PRISMA website. If you are not already using a journal article citation, they recommend that you cite one of the original publications of the PRISMA Statement or PRISMA Explanation and Elaboration.

References