Clinical Trial Documentation: Electronic Health Records, Essential Documents, and the Use of Notes to File Workshop

Maintaining the accuracy and adequacy of clinical trial documentation is both a critical component of Good Clinical Practice (GCP) and a challenge in today’s rapidly changing clinical research environment. In this workshop, learners will focus on the regulatory requirements and practical implementation of three key study documentation components: Electronic health records, essential documentation in the site’s study file, and Notes to File (NTFs).

Increasingly, investigative sites are using electronic health records for all or part of their case histories. The FDA’s expectations for source data quality, 21 CFR Part 11 compliance, and monitors’ direct access to case histories present challenges for the use of electronic health records. This module will provide some practical solutions to meet these challenges.

Understanding the big picture of how essential study documents impact the approval and ethics of a clinical research trial often gets overlooked in the rush of document collection and requests. The foundation of this module is the identification of required documents in the site study file. Participants will acquire a practical understanding of how these documents provide evidence for the regulated activities of the investigator, the sponsor, and the IRB/IEC.

The use of Notes to File, or Memos to File, has become a relatively common practice in both sponsor and site files. Regulatory authorities, however, have questioned the utility of these documents in a Quality Systems approach to clinical trial documentation. This module will provide an understanding of the right questions to ask to determine if an NTF is acceptable and the components of a quality NTF.

• Describe regulatory expectations for quality source data and electronic records
• Implement contingency planning for source document deficiencies
• Effectively manage site and sponsor activities regarding electronic health records
• Evaluate essential documents for GCP compliance and standards
• Recognize the role of essential documents as evidence for completion of regulatory responsibilities and quality study conduct
• Apply best practices for essential document review and handling
• List the questions one should ask when determining the appropriateness of an NTF
• Identify the appropriate use of NTFs in both patient-related and study-related situations
• Write an effective NTF for an applicable site management scenario

• Investigators
• Clinical Research Coordinators
• Clinical Research Associate Managers
• Clinical Research Associates/Monitors
• Project and/or Study Managers
• Project and/or Clinical Trial Assistants
• Quality Assurance Personnel

This course will be taught by one of the following instructors:

Linda Carter, R.N., B.S.N.

Nikki Christison, B.S., C.C.R.A.

Gary B. Freeman, M.S., C.C.R.A.

Click here for complete trainer biographies 

Day One: 9:00 a.m. – 4:00 p.m. Eastern (Lunch Break will run from approximately 12:00 - 1:00 p.m.) 

• Electronic Health Records
• Essential Documents
• Notes to File

• Evaluate the characteristics of a simulated electronic health record environment for Part 11 acceptability and quality data standards
• Participants should come prepared to use the guidance and tools from the course to design a risk-based monitoring strategy and contingency plan for a current work situation
• For each required essential document, attendees will identify its role in documenting a particular research partner’s regulated responsibility
• Learners are encouraged to bring specific work-related document samples, process maps, checklists, etc., and will have the opportunity to evaluate these in light of best practices and GCP standards
• Review several scenarios and associated NTFs, and evaluate if the NTF was the most appropriate manner for managing and documenting the issue
• Participants are encouraged to bring a specific work-related case study to determine whether a NTF would be appropriate, and if so, to practice writing the effective NTF

$800 by Early Bird Deadline noted in Upcoming Courses section above

$1,000 after Early Bird Deadline

This course is for individual registrants only and does not allow for group training. All participants are eligible for "Certificates of Attendance," and accreditation, provided that accreditation requirements are met. 

Barnett International is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education.  Participants will receive 6 hours (0.6 CEUs) of continuing education credit for full participation, including the completion of a pre-test, post-test, and program evaluation.  Barnett International will mail ACPE statements within three weeks of program completion.  ACPE#: 0778-0000-13-015-L01-P.  Released: 2/13. 

Hold this course at your company! For more information, contact Naila Ganatra at (215) 413-2471.