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Documentation may refer to the process of providing evidence ("to document something") or to the communicable material used to provide such documentation (i.e. a document). Documentation may also (seldom) refer to tools aiming at identifying documents or to the field of study devoted to the study of documents and bibliographies


Clinical research documentation: A hot job

We must be sure to document our efforts and our findings. Clinical research documentation is a continually expanding industry because of growing biotechnology. Salaries are paid based on ones qualification and also on their background and education. If you have the experience, flexible job options (home based, part-time, consultant) are available. Travel and in-house jobs are available too.

Clinical research documentation- job profile

The job profile could be that of a data coordinator, clinical data reviewer, medical communications consultant, drug safety specialist, or clinical research coordinator depending on your qualification and experience.

Research conditions keep changing over time and documentation should reflect all the research practices. So, the ongoing clinical research and the progress must be documented. Clinical research documentation is also useful for other purposes such as insurance, lawyers and other physicians. Laboratory, imaging and specialist consults must also be included in the documents. The clinical impressions and the case progress should be incorporated in a clinical research document.

The document should accurately reflect clinical thought processes and should document the person’s status and how the patient has progressed since research was initiated. This aspect of documentation should not be neglected and correct charting will help in successful researching.

A Clinical Research Associate (CRA) is an individual who oversees the progress and conduction of a clinical trial that is usually implemented by physicians at hospitals, clinics, or research foundations. The CRA frequently has a background of nursing, medical technology, physical therapy, bachelor's, masters, or a Ph.D. in a science and is employed by a pharmaceutical company, research organizations, or an academic institution. A CRA plays an important role in documenting drug development and thus marketing the tested drugs. The demand for trained CRAs is growing but the availability is quite limited.

Documents should have easy data entry procedures and simple review procedures. Abbreviations can be used, but should be standardized. Interpretation by others should be possible. Documents can be of great use when other specialists need information on the research.
Responsibilities may include the following:

* Monitoring that the research follows proper clinical practices and the maintenance of accurate protocol.
* Perform a study on drug (drug under study) liability;
* Verify that the documentation of the informed consent process for each study subject is accurate and periodic.
* See that all the adverse experiences are correctly reported and documented
* Check the completeness and accuracy of the case report.
* Monitor that the documentation is done every day or periodically.
* Try to increase the uses and the efficiency of clinical documentation.
* Ensure efficient chart organization.
* Check efficient chart renewal.

There are two problems involved with research-oriented recordkeeping. First of all, it takes practice and time to learn to use it effectively. This could stop research organizations from adopting such a system, especially when it involves modifying existing documents and documentation practices. The second disadvantage is that it needs an extra time for day-to-day chart entries. When documentation is not done, either the research steps get forgotten or wrongly interpreted. Sometimes it could be concluded that a particular incident did not occur at all.


Key Skills

Demonstrated written and verbal communication skills; ability to clearly convey technical information to a variety of audiences a plus. Strong interpersonal skills; ability to respond appropriately in stressful situations and data analysis skills are essential. Strong organizational skills and aptitude for detail are a must. Utilization review and/or inpatient concurrent prompting experience highly desirable. Inpatient concurrent coding experience a plus.