Research Study Documentation Good Intention is Not Enough!
Research Study Documentation Good Intention is Not Enough! If Robin Hood were audited. 2 Institutional Requirements An institution or when appropriate, an IRB, prepare and maintain adequate documentation of IRB activities, including the following (45 CFR 46.115): Copies of all research proposals reviewed, scientific evaluations, if any, that accompany the proposals, approved sample consent documents, progress reports submitted by
investigators, and reports of injuries to subjects Copies of all correspondence between the IRB and the investigators Statements of significant new findings provided to subjects Additionally, NIH Individual Institutes/Centers may have additional documentation requirements for the institution 3 All Rights Reserved, Duke Medicine 2007 Study and Subject Specific Requirements Study Specific: Should be able to recreate the study from the study documentation. All study documents related to the study are generally found in the
Regulatory File/Binder. Subject specific: Should tell the story of the subjects participation in the study and the conduct of the study. Use Case Report Forms and source records to document. 4 All Rights Reserved, Duke Medicine 2007 Study/Protocol Level documentation requirements 5 All Rights Reserved, Duke Medicine 2007 International Conference on HarmonisationE6 (Good Clinical Practice-GCP) Investigator (Section 4)
Ensure the accuracy, completeness, legibility, and timeliness of CRF data and in all required reports. CRF data is consistent with the source documents or the discrepancies should be explained. Maintain study documents as specified in Essential Documents (Section 8) or regulatory requirements take measures to prevent accidental or premature destruction of these documents. (Essential documents are those that allow for the reconstruction of the study and trial management, the evaluation of the study and the data quality and validity, and the verification of regulatory compliance through monitoring and auditing of the study) The case history for each individual shall document that informed consent was obtained prior to participation in the study. The investigator should maintain a list of appropriately qualified persons to whom the investigator has delegated significant trial-related duties. 6
All Rights Reserved, Duke Medicine 2007 Additional Requirements State and local laws Coordinating Center policies Sponsors (protocols) IRBs (policies/SOP) When faced with multiple regulations/laws/local policies, etc., always use the most restrictive one as long as it :
does not violate applicable regulations/laws/SOPs/policies, and does not put the subject or the data at harm/risk 7 All Rights Reserved, Duke Medicine 2007 Study Documentation To verify that subject rights and welfare were protected To ensure the integrity and credibility of the collected data To ensure the study was conducted in compliance with the protocol, regulations, institutional requirements All documentation by study staff, including investigators, coordinators, assistants and anyone who has study related contact with the participant Study related documents/data study staff initiate, receive, or send
Documentation by other clinical providers (i.e. consults) Documentation by other entities involved in the study (i.e. core laboratory) SOP should include procedure for documentation, and where documents are stored (Research Data and Security Plan) 8 All Rights Reserved, Duke Medicine 2007 Standard Operating Procedures Usually referred to as SOPs Should be developed for every study and define how protocol activities are performed Allows for consistency and reproducibility of study procedures and results SOPs should include a procedure for documentation,
and where the documents are kept and stored. 9 All Rights Reserved, Duke Medicine 2007 Regulatory Documentation Regulatory Files are the repository for a studys essential documents Before any trial can begin, federal and sponsor required regulatory documents will be collected. Usually the originals are kept at the site and copies are provided to the sponsor. 10 All Rights Reserved, Duke Medicine 2007
Regulatory File Keep one regulatory file for each study: Binder Filing Cabinet Drawer Electronic Documents are filed in order under each main tab and are organized in reverse chronological order (the most recently dated item is filed at the front of the section) As the contents exceed the capacity of one binder or file box, additional binders/boxes are added. The Table of Contents should list the binder or box number in which each section is located. Files will have varying documents depending on regulations being followed Subject files are kept separately Keep file audit ready
11 All Rights Reserved, Duke Medicine 2007 Required Documents Signed, IRB approved protocol and amendments (and any SOPs if not spelled out in protocol). IRB approved consent forms (all approved versions) IRB approval letters IRB Member Roster Delegation of Authority log Form 1572, if applicable Financial disclosure forms CVs and licenses Current laboratory certification (plus the archive of previous approvals)
Training records of staff 12 All Rights Reserved, Duke Medicine 2007 SIGNATURE AND DELEGATION OF RESPONSIBILITY LOG Investigator:____________________________________________________ Site:________________________ Effective Date:____________ Protocol Number/Title: Name (Please Print) Title
General Responsi bilities* Dates of Responsibilities C.V. Available From (dd/mm/yy) To (dd/mm/yy)
Signature Initials Approved (PI Initials) Yes No Yes No Yes No Yes No
Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes
No This log should include the investigator and sub-investigator(s), study coordinator(s) and all other clinic staff who routinely see study subjects and who have specific data collection/interpretation/management responsibilities. This log should also include any contracted specialists performing protocol required examinations. New or replacement staff should be added as appropriate. * Please see Legend (page 2 of 2) 13 All Rights Reserved, Duke Medicine 2007 Note/Memo to File Clarify missing or inaccurate data or procedures Document problem, document corrective action, institute corrective action May be study level or subject level, thus memo may be filed in regulatory binder or the research record Not a replacement for a reportable violation to the IRB Examples:
Assessment missed or completed out of sequence Unable to obtain a blood sample at a visit Subject failed to initial one page of a consent document Original document is destroyed and only a copy remains Subject lost to follow-up Subject dropped from study A note to file is not a panacea for all things that have gone wrong, nor a replacement for a reportable violation. 14 All Rights Reserved, Duke Medicine 2007 What should NOT be kept in a Regulatory File? Internal Audit Reports
Study Budgets Study Contract Information 15 All Rights Reserved, Duke Medicine 2007 Subject Level documentation requirements 16 All Rights Reserved, Duke Medicine 2007 Subject Specific Documentation Attributable
It should be obvious who wrote or did what Contemporaneous Legible Capable of being read In a human-readable format Changes dont obscure
original entry Print name if signature is illegible The notation, signature, and date need to be completed at the same time and as close to the event as possible Original First recording of the information (paper, electronic)
Accurate Errors have been identified and corrected 17 All Rights Reserved, Duke Medicine 2007 Corrections to Documentation Proper Notation of Corrections: One line through, write new data, initial, date and explain (if necessary) 05/10/2011 05/10/2012 LJD
Unacceptable: Obliteration, correction fluid, write overs New information must not obliterate previous information Erasing/Recording in pencil ExceptionsDo Not edit subjects personal writings 18 All Rights Reserved, Duke Medicine 2007 Source Data All information in original records and certified copies of original records of clinical findings, observations or other activities in a clinical trial necessary for the reconstruction and evaluation of the study.
19 All Rights Reserved, Duke Medicine 2007 Source Data and Documentation Source Data provides: The reconstruction and evaluation of the study Confirmation of subject existence and observations Substantiation of study data integrity Source Documents: All information in original records and certified copies of original records (ICH GCP 1.51) Include: Clinical findings, Observations, and Other study activities The first time data is captured: napkin, report, log, database 20
All Rights Reserved, Duke Medicine 2007 Examples of Source Documents A record which contains ORIGINAL data in the format and medium it was captured: Medical records Lab reports X-rays, ECGs Intake/Screening forms Telephone contact records, faxes, e-mails Subject diaries Informed consent forms Drug disposition records 21 All Rights Reserved, Duke Medicine 2007
Data Collection Tools: CRFs and Databases Record of the protocol required data for the study Forms the basis for analysis of the study data Standardizes the collection of data to help ensure that the medical, statistical, regulatory and data management needs of the study are met (SOP) 22 All Rights Reserved, Duke Medicine 2007 CRFs: Can be paper or electronic Information is complete, accurate and legible All fields are completed
Use ND or NA (follow SOP rules) 23 All Rights Reserved, Duke Medicine 2007 Direct Electronic Data Capture Diaries: participants are asked to enter data into a device provided by sponsor on regular basis Collection of direct responses from participants to questionnaires Directly enter source information in a database 24 All Rights Reserved, Duke Medicine 2007
INFORMED CONSENT 25 All Rights Reserved, Duke Medicine 2007 Informed Consent Use the current IRB-approved, watermarked consent form version (print out from the eIRB site, know when it changes) 2 subject identifiers in upper right-hand corner of each page (HIM requirement for subjects recruited from a Duke patient pool.) Each page initialed by subject at bottom (IRB requirement) Signed and dated by both the subject and the person obtaining consent
26 All Rights Reserved, Duke Medicine 2007 Consent Documentation Subject given a signed and dated copy of ICF Copy of the ICF in the subjects DUHS medical record (if Duke Medicine patient). Study team keeps the original signed consent form Healthy Controls/Non-Duke Patients must receive a copy of the Duke Health Enterprise Notice of Privacy Practices Brochure at the time of consent 27 All Rights Reserved, Duke Medicine 2007
Consent Process Note Example Date/Time: MRN: ___________ Patient Name:___________________ Consent Process Note I was asked to see Mr./Ms. ___________________ by the clinical team/MD to discuss Pro000xxxxx and name of study. The study was explained in detail and the informed consent document reviewed. The patient was given the opportunity to ask questions. All questions were answered to the patients satisfaction. The subject/participant voluntarily signed and dated the informed consent document. No study procedures were performed prior to the signing of the consent form. The participant was given a copy of the signed and dated consent form, a copy was sent to medical records and the original was place in the study file. This participant has met study entry requirements and has signed informed consent for the above study. Please authorize this participant for the eIRB 00012345 approved
Schedule of Events. ____________________________ Person Obtaining Consent ____________________________ Investigator 28 All Rights Reserved, Duke Medicine 2007 Retaining Research Documents Duke requires all research documents be stored for 6 years after the study is closed or the longer of when the youngest child on the study is 21 for pediatric trial, unless otherwise specified in a Clinical Trial Agreement. Do not shred source documents, consent forms, case
report forms, IRB documentation until the time period for retaining study documents has passed. For studies where there was no enrollment, but the IRB-approved, you are still required to keep all study documents for 6 years. 29 All Rights Reserved, Duke Medicine 2007 Storing Research Documents Sponsors using eCRFs now provide sites with a CD of data at the end of the study The site is responsible for checking to verify that the data can be read/accessed May use the Duke storage facility for long term storage of study records including the CD.
30 All Rights Reserved, Duke Medicine 2007 Importance of Documentation Over the past 5 years, 25-30% of all warning letters from the FDA to Investigators were related to inadequate/inaccurate records This is the 2nd most sited deficiency in the country 31 All Rights Reserved, Duke Medicine 2007 Examples of cited issues
Unscheduled visits not documented Phone follow-up not documented Lack of medical history files Retroactive handwritten annotations without dates Discrepancies between clinic notes, clinic visit forms, source document worksheets and CRFs 32 All Rights Reserved, Duke Medicine 2007
In Summary If it happeneddocument it! If it was supposed to happen and didnt, document and explain! Be thorough and timely in your documentation Quality checks periodically during study and before archiving If you find documentation errors, be pro-active and file a deviation/ note to file and activate a corrective action plan 33 All Rights Reserved, Duke Medicine 2007
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