This document discusses the importance of documentation and provides guidance on documentation requirements and best practices. It makes three key points:
1) Documentation is critical as it demonstrates what was done, how it was done, when, and by whom, which is necessary for study reconstruction and to justify the study to regulators. Missing or incomplete documentation can invalidate study results.
2) The main requirements for documentation are that it must be identifiable, prompt, accurate, legible, and signed/dated. It should show what was done, how, when, and by whom. Any corrections must be explained, signed, and dated.
3) Proper documentation practices include recording data directly without transcription, completing all required fields, signing