What You Must Know About PRISMA Flow Chart
Essential Knowledge for Systematic Review Success
The PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) flow chart is an essential tool for documenting the systematic review process. Understanding its proper implementation ensures transparency, reproducibility, and compliance with international publication standards.
PRISMA Flow Chart is Mandatory for High-Impact Journals
The PRISMA flow chart is not optional for systematic reviews submitted to reputable journals. Most high-impact medical and scientific journals, including those indexed in PubMed, Scopus, and Web of Science, require strict adherence to PRISMA guidelines. Manuscripts lacking proper PRISMA flow diagrams face immediate desk rejection or requests for major revisions. The flow chart demonstrates methodological transparency and allows peer reviewers to assess the comprehensiveness of your literature search and study selection process. Updated PRISMA 2020 guidelines have introduced enhanced reporting requirements, making compliance even more critical for publication success.
Professional support from publication experts ensures your PRISMA flow chart meets all journal-specific requirements and international standards.
Four Sequential Phases Must Be Documented
The PRISMA flow chart structures the systematic review process into four mandatory phases: Identification, Screening, Eligibility, and Inclusion. Each phase requires precise numerical documentation. The Identification phase reports total records found across all databases plus additional sources. The Screening phase documents records after duplicate removal and those excluded during title/abstract review. The Eligibility phase shows full-text articles assessed and those excluded with specific reasons. The Inclusion phase presents the final number of studies in qualitative synthesis and quantitative meta-analysis. Missing any phase or providing incomplete numbers violates PRISMA standards and compromises manuscript credibility.
Researchers conducting complex systematic reviews benefit from professional manuscript writing services that ensure accurate phase documentation and compliance.
Exclusion Reasons Must Be Specific and Categorized
PRISMA guidelines require detailed reporting of why studies were excluded during full-text assessment. Generic statements like “did not meet inclusion criteria” are insufficient. Reviewers must categorize exclusions into specific reasons: wrong population, wrong intervention, wrong comparator, wrong outcome, wrong study design, insufficient data, duplicate publication, or full text unavailable. Each excluded study should be assigned to one primary exclusion category. This specificity enables readers to understand selection decisions, assess potential bias, and evaluate the appropriateness of inclusion criteria. Journals increasingly request supplementary files listing all excluded studies with individual exclusion reasons, making meticulous documentation essential from the start of the review process.
Independent Dual Screening is Best Practice Standard
While PRISMA does not explicitly mandate dual screening, independent review by two researchers represents the gold standard for minimizing selection bias and improving reliability. Single-reviewer screening is generally considered inadequate for rigorous systematic reviews. At minimum, dual screening should be conducted for full-text eligibility assessment, though many journals expect it for title/abstract screening as well. Disagreements between reviewers should be resolved through discussion or third-party adjudication. Reporting inter-rater reliability statistics such as Cohen’s kappa demonstrates methodological rigor. The PRISMA flow chart should indicate whether dual screening was performed, though the diagram itself does not show individual reviewer decisions.
For teams requiring additional reviewer capacity, data extraction and screening services provide expert second reviewers to ensure methodological quality.
PRISMA 2020 Updates Changed Reporting Requirements
The PRISMA 2020 update introduced significant changes to flow diagram structure and reporting requirements. The updated flow chart accommodates database-specific reporting, showing records identified from each database separately before combining. New guidance addresses reporting of automation tools, deduplication methods, and records excluded before screening. PRISMA 2020 also introduced separate flow diagrams for different review types including updates of previous reviews and reviews of individual participant data. Researchers must determine whether their target journal requires PRISMA 2009 or PRISMA 2020 compliance, though most now expect the updated version. The PRISMA website provides free flow diagram generators ensuring compliance with current standards.
Numbers in Flow Chart Must Match Manuscript Text
A common manuscript rejection reason is discrepancies between numbers reported in the PRISMA flow chart and those stated in the methods or results sections. Every number in the flow diagram must correspond exactly to text descriptions. For example, if the flow chart shows 847 records identified through database searching, the methods section must report this identical number. Similarly, the number of studies included in meta-analysis shown in the flow chart must match the number of studies in forest plots and results tables. Peer reviewers meticulously check for these inconsistencies, which suggest careless methodology or data management errors. Maintaining a master tracking spreadsheet throughout the review process helps ensure numerical consistency across all manuscript components.
Professional manuscript editing services verify numerical consistency between flow charts and manuscript text, preventing common rejection causes.
Flow Chart Alone Does Not Ensure PRISMA Compliance
While the PRISMA flow chart is the most visible component of PRISMA reporting, complete compliance requires the 27-item PRISMA checklist covering all manuscript sections from title through funding. The flow diagram addresses only items related to study selection. Researchers must also report detailed search strategies, quality assessment methods, synthesis approaches, and risk of bias evaluations. Most journals require submission of a completed PRISMA checklist as supplementary material, with page numbers indicating where each item is addressed in the manuscript. Focusing solely on the flow chart while neglecting other PRISMA elements results in incomplete compliance and potential manuscript rejection. Comprehensive PRISMA adherence demonstrates methodological sophistication and increases acceptance likelihood at high-impact journals.
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Last Updated: October 27, 2025
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PRISMA 2020 Flow Diagram Selection Guide
A Comprehensive Guide to Selecting and Creating the Appropriate PRISMA Flow Diagram for Your Systematic Review
Purpose: The PRISMA 2020 flow diagram depicts the flow of information through the different phases of a systematic review. It maps out the number of records identified, included and excluded, and the reasons for exclusions.
Key Update: PRISMA 2020 provides four different templates depending on the type of review (new or updated) and sources used to identify studies (databases and registers only, or databases, registers and other sources).
Step 1: Determine Your Review Type and Search Sources
Question 1: Is this a new systematic review or an update of a previous review?
A new review starts from scratch, while an updated review builds upon a previously published systematic review.
Question 2: What sources did you use to identify studies?
Option A: Databases and registers only (e.g., PubMed, Embase, CENTRAL, ClinicalTrials.gov)
Option B: Databases, registers AND other sources (e.g., citation searching, websites, organizational contacts, hand searching)
Step 2: Select the Appropriate Template
Based on your answers to the questions above, select one of the four official PRISMA 2020 flow diagram templates. Each template is available as an editable Word document from the official PRISMA website.
Template 1: New Review
Databases and Registers Only
Use when: Conducting a new systematic review using only bibliographic databases and trial registers as identification sources.
Features:
- Separate reporting for databases vs. registers
- Documents automation tools used
- Shows records removed before screening
- Tracks duplicate removal
Template 2: New Review
Databases, Registers and Other Sources
Use when: Conducting a new systematic review using databases, registers, and additional sources such as citation searching or websites.
Features:
- All features of Template 1
- Additional boxes for other sources
- Accommodates citation searching
- Flexible for website and organizational searches
Template 3: Updated Review
Databases and Registers Only
Use when: Updating a previously published systematic review using only databases and registers for the updated search.
Features:
- Shows studies from previous version
- Documents new search results
- Tracks studies carried forward
- Identifies newly included and excluded studies
Template 4: Updated Review
Databases, Registers and Other Sources
Use when: Updating a previously published systematic review using databases, registers, and additional sources.
Features:
- All features of Template 3
- Additional boxes for other sources
- Comprehensive tracking of all sources
- Complete update documentation
Step 3: Complete Your Flow Diagram
Standard PRISMA 2020 Flow Structure
Identification
Records identified from:
Databases (n = ___)
Registers (n = ___)
Records removed before screening:
Duplicate records removed (n = ___)
Records marked as ineligible by automation tools (n = ___)
Records removed for other reasons (n = ___)
Screening
Records screened (n = ___)
Records excluded (n = ___)
Eligibility
Reports sought for retrieval (n = ___)
Reports not retrieved (n = ___)
Reports assessed for eligibility (n = ___)
Reports excluded (n = ___) with reasons:
Reason 1 (n = ___)
Reason 2 (n = ___)
Reason 3 (n = ___)
Included
Studies included in review (n = ___)
Reports of included studies (n = ___)
Step 4: Key Reporting Elements Checklist
| Element | What to Report | Completed |
|---|---|---|
| Identification Phase | Number of records identified from databases and registers separately; specify if automation tools were used | ☐ |
| Duplicate Removal | Number of duplicate records removed; method used (manual or automated) | ☐ |
| Pre-screening Removal | Records removed before screening (e.g., by automation tools, wrong publication type) | ☐ |
| Screening Phase | Total records screened; number excluded at title/abstract screening | ☐ |
| Retrieval | Number of reports sought for full-text retrieval; number not retrieved | ☐ |
| Eligibility Assessment | Number of reports assessed for eligibility; number excluded with specific reasons | ☐ |
| Exclusion Reasons | Specific reasons for exclusion at full-text stage with counts for each reason | ☐ |
| Final Inclusion | Number of studies included in the review; number of reports of included studies | ☐ |
| Additional Searches | If applicable, studies identified through citation searching or other methods | ☐ |
Step 5: Common Scenarios and Solutions
Solution: Use Template 2 (databases, registers and other sources). Add a separate box in the identification phase showing “Records identified through citation searching (n = ___)”. Merge these with database records after duplicate removal.
Solution: In the identification phase, report “Records marked as ineligible by automation tools (n = ___)” before the screening phase. Specify the tool name in the methods section.
Solution: In the included phase, report both “Studies included in review (n = ___)” and “Reports of included studies (n = ___)”. The latter may be higher if studies have multiple publications.
Solution: Use Template 3 or 4 (updated review templates). These templates include boxes for studies from the previous version and allow you to document which studies were carried forward and which new studies were identified.
Step 6: Quality Checks Before Finalization
Mathematical Accuracy
Verify that numbers add up correctly at each stage. For example: Records identified minus records removed before screening equals records screened. Reports assessed for eligibility minus reports excluded equals studies included.
Terminology Consistency
PRISMA 2020 distinguishes between “records” (citations identified) and “reports” (full-text articles retrieved). Use these terms consistently throughout your flow diagram and manuscript.
Exclusion Reasons
Provide specific, mutually exclusive reasons for exclusion at the full-text stage. Common categories include: wrong population, wrong intervention, wrong comparator, wrong outcome, wrong study design, and duplicate data.
Visual Clarity
Ensure the flow diagram is readable when published. Use clear boxes, arrows, and adequate spacing. Consider using the official PRISMA 2020 templates or automated generation tools for consistency.
Additional Resources and Tools
Official PRISMA 2020 Website
Download all four editable templates in Word format from the official PRISMA website:
PRISMA Flow Diagram Generator (Shiny App)
Generate PRISMA 2020 flow diagrams automatically using an interactive web application. This tool allows you to input your numbers and generates a publication-ready flow diagram:
PRISMA 2020 Explanation and Elaboration
For detailed guidance on each element of the flow diagram and the complete PRISMA 2020 checklist, consult the official explanation and elaboration paper:
Page MJ, Moher D, Bossuyt PM, et al. PRISMA 2020 explanation and elaboration: updated guidance and exemplars for reporting systematic reviews. BMJ 2021;372:n160. doi: 10.1136/bmj.n160
License Information: The PRISMA 2020 flow diagram templates are distributed in accordance with the terms of the Creative Commons Attribution (CC BY 4.0) license, which permits others to distribute, remix, adapt and build upon this work, for commercial use, provided the original work is properly cited. To view a copy of this license, visit https://creativecommons.org/licenses/by/4.0/
Detailed Guide- Phase 1: Identification in the PRISMA Flow Chart
The identification phase represents the foundation of any systematic review following the PRISMA flow chart guide. This critical initial stage involves comprehensive database searching to capture all potentially relevant studies addressing your research question. Proper execution of the identification phase ensures literature coverage completeness and minimizes selection bias in your systematic review.
Database Selection and Search Strategy
Successful identification begins with selecting appropriate databases covering your research domain. For medical and health sciences systematic reviews, researchers typically search PubMed/MEDLINE, Embase, Cochrane Library, Web of Science, and Scopus. Discipline-specific databases such as PsycINFO for psychology research or CINAHL for nursing studies may be necessary depending on your review scope.
Essential Steps for the Identification Phase
- Develop comprehensive search strings: Utilize Boolean operators, MeSH terms, and keyword variations to maximize sensitivity while maintaining specificity
- Document search dates: Record exact dates of database searches for reproducibility and future updates
- Search multiple databases: Minimum three major databases recommended, with additional discipline-specific sources as appropriate
- Include grey literature: Search conference proceedings, dissertations, clinical trial registries, and preprint servers to minimize publication bias
- Hand-search reference lists: Review bibliographies of key articles and relevant systematic reviews for additional studies
- Contact experts: Reach out to leading researchers in your field to identify unpublished or in-press studies
The identification phase documentation in your PRISMA flow chart must specify the total number of records identified through database searching and the number of additional records identified through other sources. According to BMJ guidelines on systematic review methodology, transparent reporting of search strategies enables readers to assess the comprehensiveness of your literature search and facilitates review updates.
Expert Tip for Identification Phase
Export all identified records with complete citation information including abstracts, keywords, and database source. This metadata proves invaluable during screening phases and manuscript preparation. Consider using reference management software such as EndNote, Mendeley, or Zotero to organize identified records efficiently.
Phase 2: Screening in the PRISMA Flow Chart
The screening phase of the PRISMA flow chart guide involves systematic evaluation of identified records to exclude obviously irrelevant studies while retaining potentially eligible articles for full-text assessment. This two-step process begins with duplicate removal followed by title and abstract screening against predefined inclusion and exclusion criteria.
Duplicate Removal Process
Before screening begins, researchers must identify and remove duplicate records that appear across multiple databases. Modern reference management software provides automated duplicate detection, but manual verification remains essential to catch duplicates with minor citation variations. The PRISMA flow chart requires reporting the number of records remaining after duplicate removal.
Title and Abstract Screening Methodology
Title and abstract screening represents the first substantive evaluation of identified records. Two independent reviewers should screen each record against predefined eligibility criteria, with disagreements resolved through discussion or third-party adjudication. This dual-reviewer approach, recommended by Cochrane Handbook for Systematic Reviews, minimizes individual bias and improves screening reliability.
Best Practices for Screening Phase
- Establish clear criteria: Document specific inclusion and exclusion criteria before screening begins
- Conduct pilot screening: Test criteria on sample of records to ensure consistent application between reviewers
- Use screening software: Employ tools like Covidence, Rayyan, or DistillerSR to facilitate independent dual screening
- Apply liberal inclusion: When uncertain, include records for full-text review rather than excluding prematurely
- Calculate inter-rater reliability: Report Cohen’s kappa or similar statistics to demonstrate screening consistency
- Document exclusion reasons: Track reasons for exclusion to inform PRISMA flow chart reporting
The screening phase documentation in your PRISMA flow chart must specify the number of records screened and the number of records excluded with reasons. This transparency enables readers to evaluate the appropriateness of your screening decisions and assess potential selection bias in your systematic review.
| Screening Component | Reporting Requirement | PRISMA Element |
|---|---|---|
| Records after duplicates removed | Exact number with percentage reduction | Mandatory |
| Records screened | Total number undergoing title/abstract review | Mandatory |
| Records excluded | Number with primary exclusion reasons | Mandatory |
| Inter-rater reliability | Kappa statistic or percentage agreement | Recommended |
For researchers requiring assistance with systematic screening processes and PRISMA flow chart development, our publication support services provide expert guidance on screening methodology, software selection, and documentation standards that meet journal requirements.
Phase 3: Eligibility Assessment in the PRISMA Flow Chart
The eligibility phase of the PRISMA flow chart guide involves detailed full-text assessment of articles that passed title and abstract screening. This comprehensive evaluation determines final study inclusion based on detailed eligibility criteria including study design, population characteristics, intervention specifications, outcome measures, and methodological quality standards. The eligibility phase represents the most time-intensive component of systematic review methodology, requiring careful documentation of exclusion reasons for transparency and reproducibility.
Full-Text Retrieval and Assessment
After identifying potentially eligible studies through screening, researchers must obtain complete full-text articles for detailed evaluation. In some cases, full texts may be unavailable due to access restrictions, language barriers, or incomplete publication information. The PRISMA flow chart requires reporting the number of full-text articles assessed for eligibility and documenting any articles excluded due to retrieval failure.
Detailed Eligibility Criteria Application
Full-text eligibility assessment applies comprehensive inclusion and exclusion criteria that cannot be adequately evaluated from abstracts alone. Two independent reviewers should assess each full-text article, with systematic documentation of exclusion reasons using predefined categories. This rigorous approach, endorsed by Journal of Clinical Epidemiology standards, ensures transparent decision-making and facilitates peer review of systematic review methodology.
Critical Elements of Eligibility Assessment
- Study design verification: Confirm studies meet specified design requirements such as randomized controlled trials, cohort studies, or case-control studies
- Population characteristics: Verify participant demographics, disease characteristics, and setting match inclusion criteria
- Intervention specifications: Assess whether interventions, exposures, or diagnostic tests align with review scope
- Outcome measurement: Confirm studies report outcomes of interest using appropriate measurement methods
- Comparator groups: Evaluate whether control or comparison groups meet review requirements
- Publication completeness: Ensure sufficient methodological detail for quality assessment and data extraction
- Language and timeframe: Apply any language restrictions or publication date limits specified in protocol
Common Exclusion Reasons in Eligibility Phase
The PRISMA flow chart requires reporting specific reasons for full-text exclusions. Common exclusion categories include wrong population, wrong intervention, wrong comparator, wrong outcome, wrong study design, insufficient data, duplicate publication, and full text unavailable. Documenting the primary reason for each exclusion enables readers to understand the basis for study selection decisions and assess potential selection bias.
| Exclusion Category | Definition | Example |
|---|---|---|
| Wrong Population | Study participants do not match eligibility criteria | Review focuses on adults but study includes pediatric patients |
| Wrong Intervention | Intervention differs from review scope | Review examines drug therapy but study evaluates surgical intervention |
| Wrong Outcome | Study does not report outcomes of interest | Review requires mortality data but study reports only surrogate markers |
| Wrong Study Design | Study design does not meet inclusion criteria | Review includes only RCTs but study is observational |
| Insufficient Data | Inadequate information for quality assessment or synthesis | Conference abstract without full publication or missing key data |
Managing Disagreements in Eligibility Assessment
Disagreements between independent reviewers during eligibility assessment are common and expected. Systematic reviews should establish predefined protocols for resolving conflicts, typically involving discussion between reviewers followed by third-party adjudication if consensus cannot be reached. Reporting the frequency of disagreements and resolution methods enhances transparency in your PRISMA flow chart documentation.
For complex systematic reviews requiring sophisticated eligibility assessment and PRISMA flow chart development, our publication support services provide expert methodological guidance ensuring compliance with international standards and journal-specific requirements.
Phase 4: Final Inclusion in the PRISMA Flow Chart
The inclusion phase represents the culmination of the PRISMA flow chart guide process, documenting the final set of studies incorporated into qualitative synthesis and, where appropriate, quantitative meta-analysis. This final phase requires clear reporting of the number of studies included in the systematic review, along with the number of studies and participants contributing to each specific analysis or outcome assessment.
Qualitative Synthesis and Quantitative Meta-Analysis
Studies meeting all eligibility criteria proceed to inclusion in qualitative synthesis, which involves narrative description of study characteristics, methodological quality, and findings. When studies are sufficiently homogeneous in population, intervention, comparator, and outcome measurement, quantitative meta-analysis may be appropriate. The PRISMA flow chart should specify the number of studies included in qualitative synthesis versus quantitative meta-analysis, as these numbers may differ based on data availability and heterogeneity considerations.
Quality Assessment of Included Studies
Before data extraction and synthesis, included studies undergo systematic quality assessment using validated tools appropriate to study design. For randomized controlled trials, the Cochrane Risk of Bias tool represents the gold standard. Observational studies may be assessed using the Newcastle-Ottawa Scale or similar instruments. Quality assessment informs sensitivity analyses, GRADE evidence rating, and interpretation of systematic review findings.
Quality Assessment Tools by Study Design
Randomized Controlled Trials: Cochrane Risk of Bias 2.0 tool evaluating randomization process, deviations from intended interventions, missing outcome data, outcome measurement, and selective reporting
Cohort Studies: Newcastle-Ottawa Scale assessing selection of cohorts, comparability of groups, and outcome ascertainment
Case-Control Studies: Newcastle-Ottawa Scale adapted for case-control design evaluating case definition, representativeness, control selection, and exposure assessment
Diagnostic Accuracy Studies: QUADAS-2 tool examining patient selection, index test, reference standard, and flow and timing
Data Extraction and Synthesis Planning
Following final inclusion determination, researchers extract detailed data from included studies using standardized forms. Extracted information typically includes study characteristics, participant demographics, intervention details, outcome data, and quality assessment results. Systematic data extraction facilitates evidence synthesis and enables readers to evaluate the comprehensiveness and rigor of your systematic review methodology.
Essential Components of Inclusion Phase Reporting
- Total studies included: Report exact number of studies meeting all eligibility criteria and included in systematic review
- Studies in qualitative synthesis: Specify number of studies contributing to narrative synthesis and descriptive analysis
- Studies in quantitative synthesis: Document number of studies included in meta-analysis for each outcome
- Total participants: Report aggregate sample size across all included studies
- Study design distribution: Describe types of studies included such as RCTs, cohort studies, or cross-sectional studies
- Geographic distribution: Summarize countries and regions represented in included studies
- Publication timeframe: Document range of publication years for included studies
The final PRISMA flow chart provides readers with a complete visual summary of the systematic review process from initial identification through final inclusion. This transparency enables critical appraisal of your methodology, facilitates replication by other research teams, and meets publication requirements for high-impact journals including those published by Springer Nature.
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Tools and Software for PRISMA Flow Chart Implementation
Successful implementation of the PRISMA flow chart guide requires appropriate software tools for reference management, screening coordination, data extraction, and flow diagram creation. Modern systematic review software streamlines the review process, facilitates collaboration between team members, and ensures compliance with PRISMA reporting standards. Selecting appropriate tools based on your review scope, team size, and institutional resources optimizes efficiency and methodological rigor.
Screening and Review Management Software
Covidence
Web-based systematic review management platform developed in partnership with Cochrane. Covidence facilitates screening, full-text review, quality assessment, and data extraction with built-in PRISMA flow diagram generation. The platform supports independent dual review, conflict resolution workflows, and team collaboration. Particularly suitable for health sciences systematic reviews requiring Cochrane methodology compliance.
Rayyan
Free web-based application for systematic review screening with intuitive interface and mobile accessibility. Rayyan enables independent blind screening, provides collaboration features for distributed teams, and includes basic PRISMA reporting tools. The platform offers keyword highlighting and filtering functions that accelerate title and abstract screening. Ideal for researchers with limited budgets or smaller-scale systematic reviews.
DistillerSR
Comprehensive systematic review software offering customizable workflows, advanced automation features, and robust quality control mechanisms. DistillerSR supports complex review protocols, regulatory submissions, and large-scale evidence synthesis projects. The platform provides detailed audit trails, custom form builders, and integration with statistical software for meta-analysis. Preferred for pharmaceutical industry systematic reviews and regulatory submissions.
Reference Management and Flow Diagram Creation
Reference management software plays a critical role in organizing identified records, removing duplicates, and exporting citations for screening. EndNote, Mendeley, and Zotero each offer distinct advantages for systematic review workflows. For PRISMA flow diagram creation, researchers can utilize specialized tools or general diagramming software depending on customization requirements and aesthetic preferences.
| Tool Category | Recommended Software | Primary Use |
|---|---|---|
| Reference Management | EndNote, Mendeley, Zotero | Citation organization and duplicate removal |
| Screening Software | Covidence, Rayyan, DistillerSR | Title/abstract and full-text screening |
| Flow Diagram Creation | Microsoft Visio, Lucidchart, draw.io | PRISMA flow chart visualization |
| Meta-Analysis | RevMan, Stata, R (meta package) | Quantitative synthesis and forest plots |
| Quality Assessment | RoB 2 tool, ROBINS-I, QUADAS-2 | Bias assessment and quality evaluation |
Many journals now accept PRISMA flow diagrams created using the official PRISMA Flow Diagram Generator available through the PRISMA Statement website. This free tool ensures compliance with current PRISMA standards and produces publication-ready diagrams in multiple formats.
PRISMA Flow Chart Implementation Checklist
- Register systematic review protocol in PROSPERO or similar registry before beginning
- Document comprehensive search strategy including all databases, search terms, and dates
- Export all identified records with complete citation information and abstracts
- Remove duplicates systematically using reference management software
- Conduct independent dual screening with predefined eligibility criteria
- Calculate and report inter-rater reliability statistics for screening
- Document specific reasons for full-text exclusions using predefined categories
- Assess quality of included studies using validated, design-appropriate tools
- Create PRISMA flow diagram showing exact numbers at each stage
- Complete PRISMA checklist and include as supplementary material with manuscript
Frequently Asked Questions About PRISMA Flow Chart
What is the difference between PRISMA 2009 and PRISMA 2020?
PRISMA 2020 represents an updated version of the original PRISMA 2009 statement, incorporating methodological advances and addressing limitations identified over the previous decade. Key changes include expanded guidance on reporting literature searches, new items addressing risk of bias assessment and certainty of evidence, updated flow diagram structure accommodating database-specific reporting, and enhanced guidance for systematic reviews of different study types. Researchers should follow PRISMA 2020 guidelines for new systematic reviews while recognizing that many published reviews used PRISMA 2009 standards.
How many databases should be searched for a systematic review?
Comprehensive systematic reviews typically search a minimum of three major databases relevant to the research domain. For health sciences systematic reviews, this usually includes PubMed/MEDLINE, Embase, and Cochrane Library as core databases. Additional discipline-specific databases, clinical trial registries, and grey literature sources should be searched based on review scope. The goal is to achieve comprehensive literature coverage while maintaining feasibility. Document the rationale for database selection in your methods section and report all sources in the PRISMA flow chart identification phase.
Is independent dual screening required for PRISMA compliance?
While PRISMA guidelines do not explicitly mandate independent dual screening, this approach represents best practice for minimizing selection bias and improving screening reliability. Most high-impact journals expect systematic reviews to employ independent dual screening at least for full-text eligibility assessment, with many requiring it for title and abstract screening as well. Single-reviewer screening is generally considered inadequate for rigorous systematic reviews. When resource constraints limit dual screening, consider using a second reviewer for a random sample of records with inter-rater reliability reporting.
Can systematic reviews include non-randomized studies?
Systematic reviews can include any study design appropriate to the research question. While randomized controlled trials provide the highest quality evidence for intervention effectiveness, many research questions require inclusion of observational studies, diagnostic accuracy studies, or qualitative research. The key is to predefine eligible study designs in your protocol, apply appropriate quality assessment tools for each design type, and consider design-related limitations when interpreting findings. Mixed-methods systematic reviews incorporating both quantitative and qualitative evidence are increasingly common in health services research and implementation science.
How should grey literature be handled in PRISMA flow charts?
Grey literature including conference abstracts, dissertations, unpublished studies, and clinical trial registry entries should be searched systematically to minimize publication bias. The PRISMA flow chart identification phase should separately report records identified through database searching versus other sources including grey literature. During eligibility assessment, grey literature may be excluded if insufficient information is available for quality assessment or data extraction. Document the approach to grey literature in your methods section and report the number of grey literature sources identified, screened, and included in the PRISMA flow diagram.
What should be done when full-text articles cannot be obtained?
Despite best efforts, some full-text articles may be unobtainable due to access restrictions, incomplete citations, or unavailability through interlibrary loan. The PRISMA flow chart should report the number of full-text articles excluded due to retrieval failure as a separate category. Researchers should document attempts to obtain these articles including contacting authors, checking institutional repositories, and utilizing interlibrary loan services. If potentially eligible studies cannot be obtained, this limitation should be acknowledged in the discussion section as it may introduce selection bias.
How is the PRISMA flow chart different from the PRISMA checklist?
The PRISMA flow chart and PRISMA checklist serve complementary but distinct purposes in systematic review reporting. The PRISMA flow diagram provides a visual summary of the study selection process showing the number of records at each stage from identification through final inclusion. The PRISMA checklist is a 27-item instrument covering all aspects of systematic review reporting including title, abstract, introduction, methods, results, discussion, and funding. Both the flow diagram and completed checklist should be included with systematic review manuscripts, typically with the flow diagram in the main text and the checklist as supplementary material.
For additional guidance on PRISMA flow chart implementation and systematic review methodology, researchers can consult resources from University of York Centre for Reviews and Dissemination, which provides comprehensive guidance on conducting systematic reviews in health and social care.
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Conducting a rigorous systematic review following the PRISMA flow chart guide requires methodological expertise, time investment, and attention to detail. Our comprehensive publication support services provide end-to-end assistance for systematic reviews and meta-analyses, from protocol development through manuscript submission.
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Our expert team assists researchers at every stage of the systematic review process. We provide protocol development and PROSPERO registration support, comprehensive literature search strategy design, screening coordination and duplicate reviewer services, data extraction and quality assessment, statistical analysis and meta-analysis, PRISMA flow chart creation and compliance verification, manuscript writing and editing, journal selection and submission management, and response to peer reviewer comments.
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Step-by-Step PRISMA Flow Diagram Creation for Systematic Reviews (Example 1)
Example PRISMA Flow Diagram (Nature Communications, 2024)
This figure from Lidströmer, N., Davids, J., ElSharkawy, M. et al. (2024) illustrates the study selection and screening process for a large-scale systematic review and meta-analysis evaluating the feasibility of a Global Patient co-Owned Cloud (GPOC) model in healthcare data sharing.
Key Insights from the Case Study:
- The search identified 16,045 records across multiple databases, including Medline, Embase, Cochrane, Web of Science, and Scopus.
- After removing over 9,000 duplicates and ineligible records before screening, 9,362 studies proceeded to screening.
- Only 226 full-text reports were sought for retrieval; 36 were not retrievable. Of the remaining 190 assessed, 74 were included in the final review, with 12 studies contributing data suitable for meta-analysis.
- Exclusions included datasets with no numerical outcomes (n=107) and those with no relevance to the GPOC framework (n=9).
Interpretation for Learners: This PRISMA diagram provides an advanced view of systematic review flow when dealing with large, heterogeneous data sources in health systems research. It highlights best practices for documentation transparency, especially when merging results from diverse infrastructure studies.
Read the full Nature Communications article
Citation: Lidströmer, N., Davids, J., ElSharkawy, M. et al. (2024).
Systematic review and meta-analysis for a Global Patient co-Owned Cloud (GPOC).
Nature Communications, 15, 2186.
https://doi.org/10.1038/s41467-024-46503-5
PRISMA 2020: The Official Paper Gist
Explanation and Elaboration—Updated Guidance for Reporting Systematic Reviews
Published: 29 March 2021 | Journal: The BMJ | Type: Research Methods & Reporting
What Is This Paper?
This is the official explanation and elaboration document for PRISMA 2020—the updated international standard for reporting systematic reviews and meta-analyses. It provides detailed guidance on why and how to report each of the 27 items in the PRISMA 2020 checklist, with practical examples from published reviews.
Core Purpose
To facilitate transparent and complete reporting of systematic reviews, enabling readers to assess the trustworthiness and applicability of review findings. Complete reporting is essential for healthcare providers, policymakers, and other decision-makers who rely on systematic reviews to inform practice and policy.
What’s New in PRISMA 2020?
PRISMA 2009
- 27 items total
- Generic guidance
- Limited examples
- No automation reporting
- Basic flow diagram
- Quality of evidence terminology
PRISMA 2020
- 27 items (restructured)
- Detailed bullet points per item
- Real-world exemplars
- Automation tools documented
- Enhanced flow diagram
- Certainty of evidence terminology
Major Updates and Improvements
- New Flow Diagram: Separate boxes for databases versus registers; documents use of automation tools and pre-screening removals
- Registration Emphasis: Stronger requirements for protocol registration and availability statements
- Search Strategy: Full electronic search strategies must be reported for at least one database
- Risk of Bias: Updated terminology and assessment methods aligned with current tools (e.g., ROB 2, ROBINS-I)
- Certainty of Evidence: Replaces “quality of evidence” terminology; emphasizes GRADE assessments
- Data Availability: New item requiring authors to state where review data, code, and materials can be accessed
- Reporting Bias: Clearer guidance on assessing publication bias and selective reporting
By The Numbers
The Seven Main Sections
- Title: Identify the report as a systematic review
- Abstract: Structured summary of objectives, methods, results, and conclusions
- Introduction: Rationale and objectives (PICO format recommended)
- Methods: Eligibility criteria, information sources, search strategy, selection process, data collection, risk of bias assessment, and synthesis methods
- Results: Study selection (flow diagram), study characteristics, risk of bias, and synthesis results
- Discussion: Interpretation, limitations, and implications
- Other Information: Registration, protocol, support, competing interests, and data availability
What This Paper Provides for Each Checklist Item
- Explanation: Rationale for why the item is important for transparent reporting
- Bullet Points: Specific elements to report for each item
- Exemplars: Real examples from published systematic reviews
- Common Pitfalls: Guidance on what to avoid in reporting
- Related Items: Connections to other checklist items
Target Audience
Researchers writing systematic reviews for journal submission
Evaluating completeness and transparency of review reporting
Establishing reporting standards for manuscript submissions
Learning systematic review methodology and reporting standards
Bottom Line
PRISMA 2020 represents the current gold standard for systematic review reporting. This explanation and elaboration paper serves as a comprehensive implementation guide for all 27 checklist items. Adherence to these guidelines ensures transparent, reproducible, and complete reporting, which is increasingly required by high-impact journals and essential for advancing evidence-based practice.