Learn how to perform Case data entry and use the sections and fields on the Case page.

After running the Promote to Case action, all data entered on the source Inbox Item copies to the appropriate field on the Case and child records. When entering data, picklist field values are accent-sensitive. Entering a value with an accent prioritizes results with accents.

Case Data Entry Considerations

Consider the following when processing Cases:

Details Section

Use the Details section to specify general information about the Case.

Field Description
Case Number

Vault generates a Case Number and populates this field when a Case is created.

You cannot edit this field. Outside of Edit mode, hovering over the Case Number link displays the UID and Worldwide UID.

UID

This field appears when you hover over the Case Number.

The UID is a system-generated E2B-compliant unique identifier that is composed in the following format: {Country}-{Organization UID Code}-{Case Number}
where:

  1. Country: The two-letter ISO country code for the Case country. Vault first attempts to use the Country on the primary Reporter-type Case Contact. If the reporter country is unavailable, Vault uses the Event Country on the primary Case Adverse Event.
    When the country being used for the UID changes, Vault automatically updates the UID to match the new country code. This behaviour only applies to initial Cases.
  2. Organization UID Code: The value in the Organization UID Code field for the Organization associated with the Case, if available.
  3. Case Number: Vault-generated value from the Case Case Number field.
For initial Cases, Vault re-evaluates the UID when the following data changes:
  • Country on the primary Case Adverse Event
  • Country on the primary Reporter-type Case Contact

Worldwide UID

This field appears when you hover over the Case Number.

The worldwide unique case identification (WWUID) identifies an external safety case. For example, a previously submitted case received from an MAH or partner.

You can manually enter the Worldwide UID on an Inbox Item before promoting to a Case. Otherwise, Vault automatically populates the field upon Case promotion using the value in the Organization UID Code field for the Organization associated with the Case, if available.

Receipt Date

(Required) The date the event was first reported. This date starts the regulatory clock in calculating expedited reporting (for example, 7-day or 15-day reports).

Use the calendar to select the date or enter the date manually. Specify the year, month, and day at a minimum. The time is optional.

Initial Receipt Date

The Receipt Date entered on the Inbox Item becomes the Initial Receipt Date upon Case promotion.

This is a lookup field that appears for Follow-up Cases only. Because this is a lookup field, if the Receipt Date on the original Inbox Item changes after Case promotion, the audit trail on the referenced object does not reflect the change.

New Info Date

The latest date when additional information was received about the case.

Use the calendar to select the date or enter the date manually. You must specify the year, month, and day at a minimum. Time is optional.

There can be only one New Info Date per Case version. If you overwrite this field with a new date, any previously recorded New Info Dates will appear in the audit trail.

Report Type

(Required) The method in which the adverse event was reported by the primary source.

Select the appropriate report type.

Due Date

Vault calculates the Case reporting due date and populates this field using the seriousness criteria, expectedness, and watchlist tags. If the Case is re-assessed and these criteria change, Vault automatically updates the due date based on the most conservative Regulatory or Partner due date.

For more information, see Reporting Rule Parameter Reference.

Watchlist Tags

Vault automatically populates this field using causality assessments on primary Case Assessment Results.

For more information, see How Case Watchlist Tags and DMEs are Assigned.

Event (PT)

The MedDRA Preferred Term (PT) coded on the primary Case Adverse Event.

If the Case Adverse Event has not been coded, this field is blank. This field dynamically updates to match the primary Case Adverse Event.

Seriousness

The level of impact the adverse event had on the patient.

Vault automatically populates this field using the most severe seriousness criteria entered on the primary Case Adverse Event.

Listedness (Core)

Whether the primary Case Adverse Event matches to a term on the Datasheet for the Study, Product, or Product Family. Any MedDRA Lower Level Term is considered a match if it is listed on or falls under the hierarchy of the term on the Core Datasheet or Study Datasheet.

Vault populates this field using the Listedness (Core) value in the primary Case Assessment. To override Vault-calculated value, select a different option. Once overridden, Vault stops syncing the Case Listedness (Core) field with the primary Case Assessment.

For more information, see Manage Datasheets and Auto-Expectedness.

This field does not appear on layouts by default and must be added by your Admin.

Expectedness

Whether the primary Case Adverse Event is expected. That is, whether the primary Case Adverse Event matches to a term on the relevant Product Family, Product, Local, Study, and Study Product Datasheets. Any MedDRA Lower Level Term is considered a match if it is listed on or falls under the hierarchy of the term on the Datasheet.

Vault populates this field using the Expected value in the primary Case Assessment. To override Vault-calculated value, select a different option. Once overridden, Vault stops syncing the Case Expectedness field with the primary Case Assessment.

For more information, see Manage Datasheets and Auto-Expectedness.

Relatedness

Vault automatically populates this field using causality assessments on primary Case Assessment Results.

For more information, see How Case Relatedness is Calculated.

Expedited

Indicates whether the case requires expedited reporting.

Vault automatically sets this field to Yes (expedited) when one of the following conditions are met:

  1. The Case has an adverse event that matches an expedited Watchlist.
  2. The Case meets seriousness criteria and contains an unexpected adverse event (serious, unexpected case).
  3. The Case contains both an adverse event that matches an expedited watchlist and an unexpected serious adverse event.

For more information, see How Case Watchlist Tags and DMEs are Assigned.

CIOMS Remarks

Enter any comments or additional information that should be populated in the 26. Remarks field on the CIOMS I form.

For more information, see CIOMS I Generation Data Mapping.

Validation Status

The calculated Validation Result for the Case.

The following list describes the Validation Status field values:

  • Pass: No validation rule failures were found.
  • Warning: At least one validation rule has failed to pass with a Warning status.
  • Fail: At least one validation rule has failed to pass with a Fail status.
  • Hard Fail: At least one validation rule has failed to pass with a Hard Fail status.

For more information, see Case and Submission Validation.

Suppress Submission

Select this field to prevent Vault from generating Submissions or including this Case in aggregate reporting.

This field can be used to track and monitor non-submittable cases (for example, pregnancy, invalid, or nullified cases).

For more information, see Suppress Submissions of a Case Version.

Source Document

The source document for the report. Use the link in this field to navigate to the source document.

Vault populates this field automatically when a document is used to create the Case. Otherwise, you can select the document manually.

Source Literature Review

The Literature Review in Vault SafetyDocs that includes the source Literature Article for the Case.

Vault populates this field when a Literature Article is used to create a Case. Otherwise, you can select the Literature Review manually.

This field is related to the Create Inbox Item from Literature Article feature in Vault SafetyDocs. For more information, see Create Inbox Items from Literature Articles.

Source Literature Article

The Literature Article in Vault SafetyDocs that is the source for the Inbox Item.

Vault populates this field when a Literature Article is used to create a Case. Otherwise, you can select the Literature Article manually.

This field is related to the Create Inbox Item from Literature Article feature in Vault SafetyDocs. For more information, see Create Inbox Items from Literature Articles.

Version

The version of the source document. Use the link in this field to navigate to the source document.

Vault populates this field when you attach or create the Case from a source file.

Reason Received Late

Enter information to specify the reason why the case was received late.

This field does not appear on layouts by default and must be added by your Admin.

External System UID

Unique Identifier for an external system.

You can manually enter the External System UID on an Inbox Item before promoting to a Case or on the Case itself.

This field does not appear on layouts by default and must be added by your Admin.

Initial Case

When a Follow-Up Case is created, the Initial Case field for this record is automatically populated with the original Case.

This field does not appear on layouts by default and must be added by your Admin.

Special Report Classification

For reporting to the PMDA, select whether the Case is a Safety Measure Report or a Research Report.

For more information, see Process Special Report Classification Cases.

Transmission Reason

Select from the following options in the picklist:

  • Amendment
  • Nullification

When you first generate the Transmission record, this value is copied to the Reason field of the Transmission.

Transmission Reason Text

Enter up to 2,000 characters to describe the reason for the amendment or nullification.

When you first generate the Transmission record, this value is copied to the Reason Text field of the Transmission.

Access Group

The assigned Access Group based on the Case.

Vault assigns Case Access Groups that share the most details with the Case, based on the following criteria:

  • Sponsor
  • Report Type
  • Country
  • Study Type
  • Study
  • Origin
  • Intake Format and Method
  • Market Segment

This field does not appear on layouts by default. Depending on your organization's security configuration, it may be added by your Admin.

Intake Format

Displays the format the Inbox Item was created from, such as an E2B file.

This field does not appear on layouts by default and must be added by your Admin.

Intake Method

Displays the method of intake for the Inbox Item, such as Email.

Number of Cases

Displays the number of Case copies created from the open Case.

Market Segment

Displays the market segment associated with the study for Study Cases or the primary Product for postmarket Cases.

This field does not appear on layouts by default and must be added by your Admin.

Case Reportability

Displays the reportability of the Case.

Vault sets this informational field when you execute one (1) of the following actions for the Case:

  • Evaluate Regulatory Conformance
  • Recalculate Due Date
  • Evaluate Reporting Obligations

The field displays one (1) of the following values depending on the outcome of the executed action:

  • Business Partner: The Case is reportable to a Business Partner only (Distribution).
  • Health Authority: The Case is reportable to a Health Authority only (Submission).
  • Health Authority & Business Partner: The Case is reportable to a Health Authority and a Business Partner (Submission and Distribution).
  • Not Reportable: The Case is neither reportable to a Health Authority nor a Business Partner.

You can use this field to prioritize Cases.

This field does not appear on layouts by default and must be added by your Admin.

Device Details Section

For the Device Details section to appear, the Case must have a Case Product that is a Combination Product. Use this section to classify the report type and specify details specific to device type of Case Products. You can specify further product-specific details in the Device type of Case Product. If this section does not appear for a Combination Product Case, your Admin must enable the Combination Products feature to make these fields appear.

Your Admin can configure your Vault for data entry for Remedial Actions and Malfunction at the Case Product Device level. Device-specific information is synced to the Case level. This is useful for Cases that involve multiple Combination Products or a Combination Product that has multiple device constituents. For more information, see Enable Remedial Actions and Malfunction for Combination Products to make these fields appear.

Field Description
Device Report Type

The type of device report. Select one (1) or more of the following options:

  • Malfunction
  • Public Health Risk
  • Product Problem
  • Serious Injury

This field is automatically populated with "Malfunction" if the Malfunction field is set to Yes on any Combination Product Device Constituent or any Company Product with a Transmission Product Type of Device.

Device Report Type (Status)

This field is set to "Auto-Calculated" when Vault Safety automatically populates the Device Report Type field based on the Case Product Device Malfunction fields.

When the Device Report Type field is manually edited, this field updates to "Overridden".

Manually editing this field from "Overridden" to "Auto-Calculated" causes Vault to recalculate the Device Report Type field.

Malfunction Only

This field is set to Yes when each of the following conditions are met:

  • The Case Seriousness field is blank
  • The Case Device Report Type contains Malfunction
  • The Case adverse event MedDRA is either 10067482 (PT) or 10077536 (SOC)

Vault automatically populates this field, and it is read-only.

For malfunction-only cases, you can enter "None" in the Patient Initials field and leave all other patient information blank to transmit patient characteristics as None in FDA VAERS E2B R3.

Device Follow-Up Type

The reasons for the follow-up on the device-type case.

Select the options that describe the reason for the follow-up. This field is not displayed for Initial Cases.

Remedial Action

Whether remedial action was taken to address the adverse event.

If remedial action was taken, select the option that best describes the action or select Other to manually enter a text description.

Remedial Action-Other

Text description of the remedial action when there is no matching option in the picklist.

Enter a text description of the remedial action that was taken. You must set the Remedial Action field to "Other" for this field to appear and for text in this field to be exported on Transmissions.

This Case is Locked Section

The This Case is Locked section appears when a user manually locks a Case. When a case is locked, Vault prevents the users saving changes to the Case and child records until you unlock the Case. All Case child records (such as Case Assessment and Case Product) are locked, with the exception of Parental Case and Case Number records.

This section provides details on the date the case was locked and the user who locked it. This feature is not available by default unless your Admin configures the feature.

This Case is Locked Section

Field Description
Locked By

The user who manually locked the Case from editing.

Vault automatically populates this field. Users with the appropriate permissions can use this field to reassign a locked Case or clear it to unlock the Case.

Depending on your Admin's configuration, this field name may display as Assigned To.

Locked Date

The date when the case was locked.

Vault automatically populates this field.

Contacts Section

When you promote an Inbox Item to a Case, Vault copies the reporter and patient information to automatically create Case Contacts.

Types of Case Contacts

The following list describes the types of Case Contacts:

  • Reporte: Captures information about the person who reported the Case. A Reporter type of contact is created for patients or health care professionals who are also the reporter.
  • Patient: Captures information about the patient.
  • Health Care Professional: Captures information about the health care professional who treated the patient for the adverse event that resulted in hospitalization or treatment.
  • Base Case Contact: Captures information about contacts who are not reporters, patients, or health care professionals who have information relevant to the adverse event.
  • Facility: Captures information about the facility where a vaccine dosage was administered. A Case Product Dosage can then reference a Facility record using the Administration Facility field.

How Case Contacts are Automatically Created and Updated

In each new Case, Vault creates a Reporter type of Case Contact, using data from the Inbox Item contact information. Vault also copies patient information to the Reporter type of contact when the patient is also the reporter.

If the patient was not the reporter, Vault creates a separate Patient type of Case Contact. Vault determines whether the patient is also the reporter using the Patient value specified in the Reporter Qualification field on the Inbox Item.

Review the following sections to learn more about how Reporter and Patient Case Contacts are created and populated.

When the Patient is the Reporter

If the Reporter Qualification field is Patient:

  • The patient is considered the primary reporter
  • A Patient type of Case Contact is not created
  • The patient information fields are automatically populated on the primary Reporter Case Contact
    Patient Reporter
  • Any time the Patient name fields are updated on the Case, Vault automatically updates the corresponding fields on the primary Reporter Case Contact

When the Patient is Not the Reporter

If the Reporter Qualification field value is not Patient:

  • Vault creates a Patient type of Case Contact record, in addition to the Reporter Case Contact
  • The patient information fields are automatically populated on the Patient Case Contact
    Patient Contact
  • Any time the Patient name fields are updated on the Case, Vault updates the corresponding fields on the Patient Contact. You can only have one Patient Contact per Case.

If the Inbox Item did not specify these fields and they are later added to the Case directly, Vault copies the patient name fields from the Inbox Item to create a new Patient Contact.

Add a Case Contact Record

Use the Case Contacts section to enter information about the reporting sources.

  1. On the Case page, expand Contacts.
  2. Select Create.
  3. In the Create Case Contact window, select the type of contact.
  4. Complete the Create Reporter page.
  5. Select Save.

Result

The Case Contact is added to the Case.

Case Contact Details Fields

Different fields and Reason Omitted options are available in the Case Contact Details section, depending on the Case Contact type.

Field Description
Primary Source

Indicates whether or not this Reporter record is the primary source.

If this contact is the primary Reporter, select Yes.

Qualification

The contact's qualification.

Start typing for instant search or select the binoculars icon browse the available options.

Title

Enter the contact's title.

If the contact type is Reporter or Patient, you can use the Reason Omitted field if the information is unavailable.

First Name

Enter the contact's first name.

If the contact type is Reporter or Patient, you can use the Reason Omitted field if the information is unavailable.

Middle Name

Enter the contact's middle name.

If the contact type is Reporter or Patient, you can use the Reason Omitted field if the information is unavailable.

Last Name

Enter the contact's last name.

If the contact type is Reporter or Patient, you can use the Reason Omitted field if the information is unavailable.

Facility Name

Enter the name of the facility.

If the source report omits this information, use the Reason Omitted field to describe why the information is unavailable.

Facility Type

Select the type of facility.

If the source report omits this information, use the Reason Omitted field to describe why the information is unavailable.

Organization

Enter the name of the contact's organization.

If the source report omits this information, use the Reason Omitted field to describe why the information is unavailable.

Department

Enter the name of the contact's department in their organization.

If the source report omits this information, use the Reason Omitted field to describe why the information is unavailable.

Telephone

Enter the contact's telephone number.

If the contact type is Reporter, Patient, or Facility, you can use the Reason Omitted field if the information is unavailable.

Email Address

Enter the Reporter's email address. To send automatic questionnaire emails for follow-up information, both the Email Address and Email Consent Provided are required.

If the source report omits this information, use the Reason Omitted field to describe why the information is unavailable.

Fax

Enter the contact's fax number.

If the contact type is Facility, you can use the Reason Omitted field if the information is unavailable.

Best Doctor?

Designates the contact as the best physician or other health care professional to contact about the adverse event.

If the contact is the best physician or health care professional to contact about the case, select the check box.

Sent to FDA?

Indicates whether or not the case has already been reported to the FDA.

If the report has been sent to the FDA, select Yes.

Other Source Text

Enter any relevant additional information about the Reporter.

FDA 3500A Report Source

Source of the FDA 3500A report.

Use the drop-down list to choose a value.

Additional Information

Enter any additional information that cannot be captured in the other contact fields. This field appears for Health Care Professional Case Contacts only.

Facility Military Flag

Indicates whether the facility has a military designation.

If the facility is a military facility, select Yes.

If the source report omits this information, use the Reason Omitted field to describe why the information is unavailable.

Rank

To order the list of Reporters by rank, enter the rank number. Ranked records appear in ascending order on the Case and in generated ICSR documents.

Reporters ranked as 1 correspond to the primary Reporter role. If you change a Reporter to rank 1, Vault updates the rank of the previous primary Reporter to 2.

This field does not appear on layouts by default and must be added by your Admin.

Case Contact Address Fields

Use the Address section on Case Contacts to add address information about a reporter, patient, or facility. By default, the Address section does not appear for Health Care Professional types of Case Contacts.

Field Description
Street

Enter the contact's street address.

If the source report omits this information, use the Reason Omitted field to describe why the information is unavailable.

Street Line 2

Use this field to enter the second line of the street address.

City

Enter the name of the city where the contact resides.

If the source report omits this information, use the Reason Omitted field to describe why the information is unavailable.

County

Enter the county where the contact resides.

State / Province

Enter the state or province where the contact resides.

If the state or province is mapped to a domestic state code on a Country State/Province record, a picklist is available based on the Country entered. This is useful for domestic cases originating in a country, such as Spain or Italy, where the state code is required in submissions to a specific agency, such as the EMA.

If the source report omits this information, use the Reason Omitted field to describe why the information is unavailable.

Country

Select the country where the contact resides.

If the source report omits this information, use the Reason Omitted field to describe why the information is unavailable.

Postal Code

Enter the contact's zip or postal code.

If the source report omits this information, use the Reason Omitted field to describe why the information is unavailable.

Regional Section

Use the Regional section on a Domestic Case to enter region-specific agency information for the NMPA (China) agency and the MFDS (Korea) agency.

Field Description
NMPA Report Classification

The NMPA Report Classification for Chinese Cases.

Select the appropriate NMPA Report Classification for the report from the dropdown menu.

MFDS Other Health Professional

This field is only available when you select "Other Health Professional" for the reporter qualification on the Case.

Select the qualification of the reporting health professional contact from the dropdown menu.

MFDS Other Study Type

This field is only available for studies.

Select the appropriate MFDS Study Type Classification for a study from the dropdown menu.

Patient Regional Section

The following fields are available on the Case Contacts Regional section for NMPA Cases.

NMPA Patient Regional Section

Field Description
NMPA Report Source

This field is required for Cases with post-market products.

Select the origin of the report from the dropdown menu.

NMPA Patient Race

Select the patient's race for Chinese NMPA Cases.

Select the NMPA patient race from the dropdown menu.

NMPA Patient Nationality

The patient's nationality code for Chinese NMPA cases.

Enter the Chinese nationality code for the patient in the text format "XX". This field is required.

Organization

Enter the name of the contact's organization.

If the source report omits this information, use the Reason Omitted field to describe why the information is unavailable.

Patient Section

Use the Patient section to enter patient information, including a name or identifier, age, sex, height, weight, and medical record numbers (MRNs).

Field Description
Patient Known to Exist

Whether there is a known Patient involved in the Case. This information is required for reporting obligations in certain jurisdictions.

Select this field if any of the following scenarios apply:

  • There is a referenced patient in the Case
  • There is a patient, but specific patient characteristics are not available
  • There is a patient, but the patient may not be identifiable

For more information, see Reporting Rule Parameter Reference.

This field does not appear on layouts by default and must be added by your Admin.

Patient Initials

Enter the patient's initials.

If the source report omits this information, use the Reason Omitted field to describe why the information is unavailable.

Patient Name Prefix

Enter the patient's name prefix or title. This field is used in FDA VAERS reporting.

If the source report omits this information, use the Reason Omitted field to describe why the information is unavailable.

Patient First Name

Enter the patient's first name. This field is used in FDA VAERS reporting.

If the source report omits this information, use the Reason Omitted field to describe why the information is unavailable.

Patient Middle Name

Enter the patient's middle name. This field is used in FDA VAERS reporting.

If the source report omits this information, use the Reason Omitted field to describe why the information is unavailable.

Patient Last Name

Enter the patient's last name. This field is used in FDA VAERS reporting.

If the source report omits this information, use the Reason Omitted field to describe why the information is unavailable.

Investigation MRN

The unique Subject/Patient ID, Centre ID, or random number in a clinical trial.

If a clinical trial investigated the adverse event, enter the following information:

  • The patient's medical record number with a general practitioner
  • The general practitioner's record number

You can enter multiple sets of record numbers in this field.

If the source report omits this information, use the Reason Omitted field to describe why the information is unavailable.

Randomization Number

The patient's randomization number from the clinical trial randomization system.

Vault can automatically populate this field during a bulk unblind operation using the study participants CSV file. You can also enter this field manually.

For more information, see Bulk Unblind a Study.

This field does not appear on layouts by default and must be added by your Admin.

Sex

Select the patient's sex. Depending on your Admin's configuration, this field may be labeled Gender.

If the source report omits this information, use the Reason Omitted field to describe why the information is unavailable.

Gender

Select the patient's gender identity or enter a custom value of up to 100 characters.

Height

The patient's height.

In the first field, enter a number. In the second field, select the unit of measurement.

Weight

Enter the patient's weight.

In the first field, enter a numeric value. In the second field, select the unit of measurement.

Parent Information

Reference to the Parent Information Case from the current (child) case. The patient's Age at Onset must be less than 17 months (1.5 years) for this field to appear.

For a parent-child case, create or select the Parental Case to link it to the current Case. You must select a Case with the object type of Parental Case (parental_case__v). For more information, see Add a Parental Case.

Date of Birth

The patient's birth date.

Use the Calendar pop-up tool to select a date or enter the date manually. For this field to be exported to E2B Transmissions, the full date is required with year, month, and day.

If the source report omits this information, use the Reason Omitted field to describe why the information is unavailable.

Age (normalized)

The normalized Age at Onset value calculated in "years".

Vault automatically calculates Age (normalized) and uses it to populate the Age at Onset field, if no value exists already.

This field does not appear on layouts by default and must be added by an Admin to appear.

Auto-Calculation

Vault automatically calculates this field using the time interval between the following dates:

  1. The Case Date of Birth
  2. The Case Adverse Event Event Onset. If an Event Onset is not available, Vault uses the Case Receipt Date.

If you manually enter a value after the auto-calculation, Vault retains the manually entered value. If you manually enter a value and then edit one of the above fields used in auto-calculation, Vault will re-calculate and override the manually entered value, assuming there is sufficient data for calculation.

When only partial dates are available, Vault calculates the age using the first day in the month or year entered. For example, if only "2021" is entered, the date 1/1/2021 is used.

For more information, see How Age Fields are Calculated.

Age at Onset

The patient's age at the onset of the adverse event.

This field is populated by Vault-calculated Age (normalized) field. Vault automatically populates this field upon Case promotion or when the Case is updated. You can also disable auto-calculation for this field to retain the manually entered value. See Manage Auto-Calculation Override for more detail.

The age value displays the patient's current age in years. For example, if the patient's age at onset is 53 years and nine months, Vault will display 53 years old in the Age at Onset field.

If the patient is less than two years old, Vault displays the patient's current age in months. For example, if the patient's age at onset is 50 days old, Vault will display the patient's age as 1 month old in the Age at Onset field.

For more information, see How Age Fields are Calculated.

Age Group

The patient's age group at the onset of the adverse event, according to the following criteria:

Age Group Age at Onset
Fetus 0 weeks/days/hours/minutes old
Neonate More than 0 to less than 4 weeks old
Infant 4 weeks to less than 12 months old
Child 1 year to less than 12 years old
Adolescent 12 years to less than 18 years old
Adult 18 years to less than 65 years old
Elderly 65 years and older

Vault automatically calculates this field upon Case promotion or when the Age at Onset field on the Case is updated. If you manually enter a value, and Vault later recalculates this field, the field is overwritten by the auto-calculated value.

You can also disable auto-calculation for this field to retain the manually entered value. See Manage Auto-Calculation Override for more detail.

Auto-Calculation

Vault automatically calculates the age group based on the value in the Age at Onset field and the above criteria.

For more information, see How Age Fields are Calculated.

Age at Vaccination

The patient's age at the time of being administered the primary vaccine-type product. This field is used in FDA VAERS reporting.

Vault automatically calculates this field upon Case promotion or when the Case is updated. If you manually enter a value after the auto-calculation, Vault retains the manually entered value. If you manually enter a value and then edit a field used in the auto-calculation, Vault will re-calculate and override the manually entered value, assuming there is sufficient data for calculation.

You can also disable auto-calculation for this field to retain the manually entered value. See Manage Auto-Calculation Override for more detail.

Auto-Calculation

Vault automatically calculates this field when the primary Case Product is a Vaccine-type product. The age at vaccination is calculated using the time interval between the following dates:

  1. The Case Date of Birth
  2. The primary Vaccine-type Case Product Dosage First Admin Date

    If there are multiple Dosages under the primary Vaccine-type Case Product, Vault uses the earliest First Admin Date to calculate the age.

Autopsy

Indicates whether or not an autopsy was performed. This field displays if the Date of Death field has a value.

Select either Yes or No from the drop-down menu.

If the source report omits this information, use the Reason Omitted field to describe why the information is unavailable.

Date of Death

Enter the date when the patient was reported as deceased.

Use the Calendar pop-up tool to select a date or enter the date manually.

If the source report omits this information, use the Reason Omitted field to describe why the information is unavailable.

Last Menstrual Period

Enter the date when the patient last experienced a menstrual period. This field is available only if the Sex field is set to Female.

If the source report omits this information, use the Reason Omitted field to describe why the information is unavailable.

Pregnancy

Use this field to identify a case as a Pregnancy Case for tracking and capturing pregnancy information. This field is available only if the Sex field is set to Female.

For more information, see Process Pregnancy, Child Information, and Parent Information Cases.

Pregnant at Exposure

Indicates whether the patient was pregnant at the time of exposure. This field is available only if the Sex field is set to Female. This field is used in FDA VAERS reporting.

If the patient was pregnant at the time of exposure, select Yes.

If the source report omits this information, use the Reason Omitted field to describe why the information is unavailable.

Ethnicity

Select the patient's ethnicity. Start typing for instant search or use the binoculars icon to browse for the appropriate value. This field is used in FDA VAERS reporting.

If the source report omits this information, use the Reason Omitted field to describe why the information is unavailable.

Race

Select the patient's race from the drop-down list. This field is used in FDA VAERS reporting.

Specialist MRN

The patient's medical record number with a specialist and the specialist's record number.

If the patient visited a specialist for the adverse event, enter the following information:

  • The patient's medical record number with a specialist
  • The specialist's record number

You can enter multiple sets of record numbers in this field.

If the source report omits this information, use the Reason Omitted field to describe why the information is unavailable.

Hospital MRN

The patient's medical record number with a hospital and the hospital's record number.

If the patient visited a hospital for the adverse event, enter the following information:

  • The patient's medical record number with a hospital
  • The hospital's record number

You can enter multiple sets of record numbers in this field.

If the source report omits this information, use the Reason Omitted field to describe why the information is unavailable.

GP MRN

The patient's medical record number with a general practitioner and the general practitioner's record number.

If the patient visited a general practitioner for the adverse event, enter the following information:

  • The patient's medical record number with a general practitioner
  • The general practitioner's record number

You can enter multiple sets of record numbers in this field.

If the source report omits this information, use the Reason Omitted field to describe why the information is unavailable.

Concomitant Therapies

Select Yes or No to indicate whether the patient was being treated with concomitant therapies, such as radiotherapy, drug class, or dietary supplements, at the onset of the adverse event.

Military Status

The patient's military status type. This field is used in FDA VAERS reporting.

Medical History Text

Enter the patient's medical history and concurrent conditions, which could not be coded as Medical History records. If there is no medical history, you can specify "None."

Medical History Text (reason omitted)

If the source report omits the medical history, select the option that describes why this information is not available.

Add a Parent Case

For a parent-child case, use the Parent Information field in the Patient section to capture E2B-compliant parent information using a Parent Information type of Case. For guidance on adding pregnancy Cases, see Process Pregnancy, Child Information, and Parent Information Cases.

Pregnancy Information Section

For pregnancy cases, enter information about the pregnancy and outcome in the Pregnancy Information section. For guidance on adding pregnancy Cases, see Process Pregnancy, Child Information, and Parent Information Cases.

Child Information Section

Use the Child Information section to capture details about an infant born from a tracked pregnancy case, when there was no adverse event in the infant. The Pregnancy checkbox must be selected to make this section appear on the layout. For guidance on adding different birth outcomes associated with pregnancy cases, see Process Pregnancy, Child Information, and Parent Information Cases.

Products Section

Use the Products section on the Case to enter information about suspect and concomitant medications, including products suspected to have an interaction. For Cases under a Study, this section label appears as Products (Study).

case-product-section

When an Inbox Item is promoted to a Case, Vault copies the product information to create the primary Case Product record using the appropriate product type:

  • Company Product (Drug, Biologic, Device, Vaccine, or Company Product): If a Product from the company library was selected on the source Inbox Item, then Vault creates the Case Product of that type.
  • Study Product: If the Inbox Item specified a Study, then Vault copies the Study Products to the Case.
    If your Admin has preconfigured Study Arms related to the Case, the Study Products are automatically downloaded from the study arm selected in the Inbox Item.
  • External Product: If the Inbox Item does not link to a preconfigured Product, then the product details are added as an External Product.
  • Combination Product: If a Combination Product was selected on the Inbox Item, its constituents are automatically downloaded and added as separate Case Products when the Case is promoted. Each constituent Product inherits the Combination Product Drug Role.

About Company Products

The Company Product type of Company Product is used when a product has multiple Product Type registrations to meet agency reporting requirements. When Company Product is selected, the Transmission Product Type on the Registered As field from the Product Registration is copied to the Product Globally Registered As field. Available Transmission Product Types include the following:

  • Drug
  • Biologic
  • Device
  • Vaccine
  • Nutritional
  • Cosmetic
  • OTC Drug
  • OTC Device
  • Combination Product

Add a Case Product Record

When you add a Company Product that is already configured in the Product Library, Vault populates the Product details on the Case.

  1. On the Case page, expand the Case Products section.
  2. Select Create.
  3. In the Create Case Product window, complete the fields. For information on coding products based on the reported Product, see Auto-Code and Browse Products.
  4. Select Save.

Result

Vault creates the Case Product record and assigns the Product Type based on the configuration in the Product library.

Case Product Details Section

The fields that appear in the Product Details section depend on the Product type and your Vault’s configuration.

Consider the following when working with the Case Product Details section:

  • Your Admin can configure your Vault for data entry for Remedial Actions and Malfunction at the Case Product Device level. Device-specific information is synced to the Case level. This is useful for Cases that involve multiple Combination Products or a Combination Product that has multiple device constituents. For more information, see Enable Remedial Actions and Malfunction for Combination Products to make these fields appear.
  • Depending on your Admin’s configuration, suspect Case Products may include those with a Drug Role of Drug Not Administered. See Enable Extend Definition of Suspect to Drug Not Administered for details.
Field Description
Case

Reference link to the Case.

Vault automatically populates this field.

Study

Select the Study that the Study Product is associated with. Vault automatically populates this field with the Study associated with the Case. This field appears for Study Products only.

For more information, see Manage Studies.

Primary

Indicates whether the product is the primary product on the Case.

If the product is the key suspect product of interest, Select Yes. You cannot make an External Product primary.

Rank

To order Case Products by rank, enter the rank number.

Products ranked as 1 correspond to the primary product role.

If you change a product to rank 1, Vault updates the rank of the previous primary product to 2. Ranked records appear in ascending order on the Case and in generated ICSR documents.

This field does not appear on layouts by default and must be added by your Admin.

Drug Role

Select the characterization of the drug role in the adverse event as provided by the primary reporter or sender.

A valid Individual Case Safety Report (ICSR) must include at least one Case Product with a Drug Role of either Suspect, Interacting, or Drug Not Administered. For Device-type Case Products to appear on generated FDA MedWatch 3500A reports, the Drug Role must be Suspect, Interacting, or Drug Not Administered.

The following options are available by default, however your Vault may have additional Drug Role Controlled Vocabularies configured:

Drug Role Option Description
Suspect Identifies a product suspected to have contributed to the adverse event.
Interacting Identifies a product suspected to have an interaction with another product.
Concomitant Identifies a product taken by the patient at the time the reaction was observed.
Drug Not Administered

Identifies a product that was not administered, but must be reported. For example, in a clinical trial setting or due to a product administration error.

Depending on your Admin's configuration, the Drug Not Administered Drug Role may be evaluated as suspect.

Similar Device Identifies a US-marketed product (such as a vaccine) that contains the same or similar device as the suspect product for which a malfunction was reported. This option is used in FDA VAERS submissions for scenario 10 (a malfunction combination product with a similar device).
Treatment Identifies products used to treat the adverse event. This drug role is for tracking purposes only and does not appear on generated regulatory reports.

Product (Reported)

Enter the name of the product, as reported by the source. For information on coding products based on the reported Product, see Auto-Code and Browse Products.

When adding unblinded or open label Study Products to a Case, if the Product (Reported) field is blank, Vault maps the Study Product Name to this field. When adding blinded Study Products to blinded Cases, Vault maps the blinded product name from the applicable Study Product Placeholder record. When adding non-blinded Study Products to blinded Cases, Vault populates the value from the Product (Coded) field. Vault does not override the field if it is populated.

Product

A link to the Product, as configured in the Product Library .

Select the Product from the drop-down menu. The options are filtered by the Products in the Product Library under the Case Organization.

For more information, see Manage Products.

Combination Product

The combination product for which this product is a product constituent. This field appears for Combination Product Constituents only.

Vault automatically populates this field when a Combination Product was selected as the product in the source Inbox Item.

When adding or editing a Product record to include a Combination Product, related constituent Products are automatically downloaded and added as separate Case Products.

For more information, see Manage Combination Products.

Trade Name

The brand name of the device.

For Device-type products, this field is used in report generation for FDA E2B(R2) (B.4.k.20.FDA.1).

Product Code

For devices only, enter the product code classification.

Vaccine Type

The type of vaccine. This field is used in FDA VAERS reporting.

The following options are available by default:

  • Live Attenuated Viral
  • Inactivated
  • Subunit
  • Toxoid

If the source report omits this information, use the Reason Omitted field to describe why the information is unavailable.

Product Registration

A link to the Product Registration record, as configured in the Product Library .

If the product registration details are already configured in the Product Library , select the Product Registration record.

For more information, see Add Product Registration Details.

Combination Product Registration

A link to the Combination Product Registration record, as configured in the Product Library .

If the product registration details are already configured in the Product Library, select the Product Registration record.

For more information, see Combination Product Registrations.

Country Obtained

Select the country where the product was obtained.

WHODrug

Product code from the WHODrug dictionary. This field appears for External Products only. Vault populates this field only when the External Product is selected through the WHODrug Browser.

For information on browsing and coding terms from the WHODrug dictionary, see Code WHODrug Products.

JDrug

Product code from the Japan Drug Dictionary (JDD). This field appears for External Products on Domestic Cases for Japan only.

For information on browsing and coding terms from the JDD, see Code Japan Drug Dictionary Products.

MPID

Medicinal Product Identifier (MPID) for the product. This field appears after coding the WHODrug product code.

This field is automatically populated based on the selection from the WHODrug dictionary.

Version

The WHODrug version for the MPID. This field appears after coding the WHODrug product code.

This field is automatically populated based on the selection from the WHODrug dictionary.

Action Taken

Select what action was taken with the product as a result of the adverse event. Use the binoculars icon to search for Action Taken or enter the information manually.

Remedial Action

Whether remedial action was taken to address the adverse event.

If remedial action was taken, select the options that describe the actions. The following options are available by default:

  • Inspection
  • Modification/Adjustment
  • Notification
  • Other
  • Replace
  • Recall
  • Relabelling
  • Repair
  • Patient Monitoring

This field populates the applicable H7. If Remedial Action Initiated, Check Type checkboxes in the FDA 3500A form.

Remedial Action Other

Text description of the remedial action when there is no matching option in the picklist.

Enter a text description of the remedial action that was taken. You must include "Other" in the Remedial Action field for text in this field to be exported on Transmissions.

This field populates the H7. If Remedial Action Initiated, Check Type > Other field in the FDA 3500A form.

Malfunction

Whether the device failed to meet its performance specifications or otherwise perform as intended.

Select Yes or No from the picklist.

When this field is set to Yes on at least one device, Vault automatically sets the Case Device Report Type field in the Device Details section to “Malfunction”.

Based on the primary Case Device Product, this field populates the H1. Malfunction checkbox in the FDA 3500A form.

Gestation Exposure

The patient's Age at Onset must be less than 17 months (1.5 years) for this field to appear.

Enter the gestational age at the time of the earliest exposure. Enter a numeric value in the first field and select a unit of time in the second field.

Additional Information

Additional information relevant to the product and its usage.

If there is additional information relevant to the product and its usage, select an option from the list.

If you cannot describe the additional information with any of these options, type the text in the Other Additional Information field.

Other Additional Information

If none of the options in the Additional Information list apply, use this field to enter any additional product information.

Expiration Date

The product expiry date.

If Expiration Date is available, use the calendar tool to select the date or enter the date manually.

The original Expiration Date field does not accept partial dates. However, the Expiration Date control, introduced in the 22R1 release, accepts partial dates with a minimum precision of the year.

Cumulative Dose

The total cumulative dose administered until the first sign of an adverse event.

Auto-Calculation

Vault automatically calculates this field when you add or update information about the product dosage or onset of the earliest adverse event.

If you manually enter a value after the auto-calculation, Vault retains the manually entered value. If you manually enter a value and then edit a field used in the auto-calculation, Vault will re-calculate and override the manually entered value, assuming there is sufficient data for calculation.

You can also disable auto-calculation for this field to retain the manually entered value. See Manage Auto-Calculation Override for more detail.

For more information, see How Cumulative Dose is Calculated.

External Product Type

Select the product type for the external product to ensure product fields specific to product types are displayed. For example, certain fields only appear when you select Vaccine as the External Product Type. This field appears for External-type Case Products only.

This field does not appear on layouts by default and must be added by your Admin.

Globally Registered As

Displays the Transmission Product Type in the Registered As field on the Product Registration. The options include the following:

  • Drug
  • Biologic
  • Device
  • Vaccine
  • Nutritional
  • Cosmetic
  • OTC Drug
  • OTC Device
  • Combination Product

This field does not appear on layouts by default and must be added by your Admin.

Blinded Name

Vault populates this field automatically using the Blinded Name (Study Product Placeholder) from the Inbox Item Study Product field.

This field does not appear on layouts by default and must be added by your Admin.

Blinding Type

Identifies whether a Clinical Trial Study Case Product is blinded.

Vault sets this to one (1) of the following:

  • Blinded
  • Unblinded
  • Open
  • blank (for example, non-Study or External Products)

For more information, see Isolate Blinded Clinical Trial Information.

Blinded Reference

For unblinded Clinical Trial Study Case Product records, links to the associated blinded record.

For more information, see Isolate Blinded Clinical Trial Information.

Dosages Section

Use the Dosages section to add, edit, or delete dosage and route of administration regimens for a Case Product. By default, this section does not display for Device type of Case Products or Study Products associated with a double-blinded Study. When there are no Dosage records, the Case Product Dosage section control appears blank. To create a Dosage, select Edit on the Case Product page.

To create additional dosages for a Case Product, select the Add Dosages button. After saving the page, Vault displays dosages in order of the earliest to latest First Admin Date. You can also copy a Dosage record and any inputted data by selecting the Copy (Copy Button) icon. To mark a Dosage record for deletion, select the Delete (Delete Button) icon.

Field Description
Dose

The amount of product administered at one time.

Enter the (numeric) dose value in the first field. Select the Unit of Measurement for the dose from the picklist, or create a custom entry.

Frequency

Enter how often the dose was administered. Once you save the page, Vault will calculate and display an E2B-compliant description of the values. For example, 4 times per day (.25 days).

  • To enter a specific time interval, select either the first or second option depending on the preferred format.
  • If the dosage regimen is not specific to a time interval, or the exact frequency is unknown, select the third option and specify whether the regimen was "Cyclical" or "As Necessary".

    If only the total product dosage is provided, select "Total" in the third option. For example, if a patient took 100mg of a drug in total, you should enter 100mg in the Dose field and select "Total" in the Frequency field.

First Admin Date

Enter the date and time (if available) when the product was first administered.

If the source report omits this information, use the Reason Omitted field to describe why the information is unavailable.

Last Admin Date

Enter the date and time (if available) when the product was last administered.

If the source report omits this information, use the Reason Omitted field to describe why the information is unavailable.

Duration

Combined number and unit field to capture the overall duration of time that the product was administered to the patient.

Auto-Calculation

Vault automatically calculates this field once you save the Case Product Dosage, based on the values in the following fields:

  • First Admin Date
  • Last Admin Date

Vault recalculates and updates this field any time the First Admin Date or Last Admin Date values are updated. If you manually enter a value after the auto-calculation, Vault retains the manually entered value. If you manually enter a value and then edit a field used in the auto-calculation, Vault will re-calculate and override the manually entered value, assuming there is sufficient data for calculation.

You can also disable auto-calculation for this field to retain the manually entered value. See Manage Auto-Calculation Override for more detail.

Batch/Lot Number

Enter the batch or lot number for the medicinal product.

If the source report omits this information, use the Reason Omitted field to describe why the information is unavailable.

Expiration Date

The product expiry date for the batch/lot number.

If Expiration Date is available, use the calendar tool to select the date or enter the date manually.

Dose Form

Description of the pharmaceutical Dose Form.

Select an option from the picklist or use a custom entry.

Vault Safety supports a selection of dose form terms, including terms from the Extended Eudravigilance Medicinal Product Dictionary (xEVMPD) and the Medicines and Healthcare products Regulatory Agency (MHRA).

Encoded dose forms in E2B reports received and imported into Vault Safety will be mapped using these dictionary entries, including E2B(R2) codes received from the MHRA.

Patient RoA

Route of Administration code for the patient.

Select an option from the picklist or use a custom entry.

Parent RoA

Route of Administration code for the parent for a parent-child or fetus report.

Select an option from the picklist or use a custom entry.

Administration Facility

The facility where the vaccine was administered. This field is available only when the Case Product type is Vaccine or Company Product. This field is used in FDA VAERS reporting.

If the product is a vaccine, select the facility that administered the dosage. The options available in this list correspond to the Facility-type Case Contacts added to the Case.

Anatomical Site

The vaccine anatomical approach site. This field is available only when the Case Product type is Vaccine or Company Product. This field is used in FDA VAERS reporting.

Select the anatomical site to which the dosage was administered.

If the source report omits this information, use the Reason Omitted field to describe why the information is unavailable.

Dose Number in Series

Enter the dose number in the series. This field is available only when the Case Product type is Vaccine or Company Product. This field is used in FDA VAERS reporting.

Dosage Text

Enter a description of the dosage when there is information that cannot be captured in the other Dosage fields.

Blinding Type

Identifies whether a Clinical Trial Study Case Product Dosage is blinded.

Vault sets this to one (1) of the following:

  • Blinded
  • Unblinded
  • Open
  • blank (for example, non-Study or External Products)

For more information, see Isolate Blinded Clinical Trial Information.

Blinded Reference ID

For unblinded Clinical Trial Study Case Product Dosage records, references the associated blinded record if available.

For more information, see Isolate Blinded Clinical Trial Information.

Indications Section

Use the Indications section to specify the reported and MedDRA coded usage for the product in treating a medical condition.

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Field Description
Indication (Reported)

The indication for product use.

Enter the reported term in the text field, then use the Auto-Code button to automatically match and code the MedDRA term. Alternatively, use the binoculars icon to open the MedDRA browser. The MedDRA term and code appear below the field.

For more information, see Code MedDRA Terms.

If the source report omits this information, use the Reason Omitted field to describe why the information is unavailable.

Reason Omitted

The reason an indication was omitted.

Select the reason for omitting the reported indication, when applicable.

Selecting a nullFlavor automatically codes the MedDRA term "Drug use for unknown indication (10057097)” below the Indication (Reported) field.

Blinding Type

Identifies whether a Clinical Trial Study Case Product Indication is blinded.

Vault sets this to one (1) of the following:

  • Blinded
  • Unblinded
  • Open
  • blank (for example, non-Study or External Products)

For more information, see Isolate Blinded Clinical Trial Information.

Blinded Reference ID

For unblinded Clinical Trial Study Case Product Indication records, references the associated blinded record.

For more information, see Isolate Blinded Clinical Trial Information.

Device Information Section

Use the Device Information section to enter details about Device type of Case Products. By default, this section appears only for External Products and Device Products. When the Case includes a Company Product, this section appears if the Registered As field on the Product Registration is Device.

device information section

Field Description
Model Number

Enter the model number assigned to the medical device by the manufacturer.

Catalog Number

Enter the catalog number assigned to the medical device by the manufacturer.

Lot Number

Enter the lot number assigned to the medical device by the manufacturer.

Serial Number

Enter the serial number assigned to the medical device by the manufacturer.

Unique Identifier

Enter the unique identification code assigned to the medical device by the manufacturer.

Operator of Device

The operator using the medical device.

Select the type of operator from the picklist. By default, the options in this picklist are:

  • Health Professional
  • Lay Person
  • Other

Operator of Device (Other)

You must select Other in the Operator of Device field for this field to appear.

Enter a text description of the medical device operator if the Operator of Device picklist does not contain a suitable option.

Single Use

Select Yes or No to indicate whether the medical device is labeled for single use.

Reprocessed/Reused

Select Yes or No to indicate whether the single-use medical device was reprocessed and used for a subsequent application. This field populates box 7b. in the FDA 3500A form.

Reprocessor

Enter the name and contact information of the contact who reprocessed the medical device. This field populates box 7b. in the FDA 3500A form.

Date Implanted

Enter the date when the medical device was implanted in the patient.

Date Explanted

Enter the date when the medical device was removed from the patient.

Returned Date

Enter the date when the medical device was returned to the manufacturer.

Device Available

Select Yes or No to indicate whether the device is available for further evaluation.

Device Evaluated

Select Yes, No, or Not Returned to Manufacturer to indicate whether the device has been evaluated by the manufacturer. This field populates Section H Box 3. Device Evaluated by Manufacturer on the FDA 3500A form.

Manufacture Date

Enter the date when the device was manufactured.

Device Usage Type

The product usage type for the device-type product.

Use the binoculars icon to search the language corresponding with the medical device usage or start typing for instant search.

Device Age

The age of the device.

In the first field, enter a numeric value. In the second field, select a unit of time from the drop-down menu.

Correction/Removal Reporting Number

Enter the correction/removal reporting number. This must follow the format directed by 21 CFR 807. If you do not have a correction/removal reporting number, the FDA-assigned recall number can be entered.

This field populates Section H Box 9. If action reported to FDA under 21 USC 360i(f), list correction/removal reporting number on the FDA 3500A form.

Third-party servicer for device?

Select whether the device was ever serviced by a third-party servicer.

Additional Device Manufacturer Narrative

Enter any additional information, evaluation, or clarification of information previously entered.

This field populates Section H Box 10. Additional Manufacturer Narrative on the FDA 3500A form.

Case Product Device Code

The Case Product Device Code section captures the harmonized FDA/IMDRF codes for device-specific adverse events.

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Field Description
Case Product

The device for which you want to assign a problem code.

Select the binoculars icon to search for the device or start typing for instant search.

Device Code Type

Displays the seven IMDRF annex names for the categories of device codes.

Select an option from the picklist.

Device Code

After the Device Code Type field is populated, search for and select the device code from the picklist. The available options are dependent on the Device Code Type selected and the active IMDRF dictionary version.

Blinding Type

Identifies whether a Clinical Trial Study Case Device-type Product is blinded.

Vault sets this to one (1) of the following:

  • Blinded
  • Unblinded
  • Open
  • blank (for example, non-Study or External Products)

For more information, see Isolate Blinded Clinical Trial Information.

Blinded Reference ID

For unblinded Clinical Trial Study Case Product Device Code records, references the associated blinded record.

For more information, see Isolate Blinded Clinical Trial Information.

Device Problem and Evaluation Codes Section

The Device Problem and Evaluation Codes section captures FDA device codes for a Device type of combination product constituent. By default, this section only displays for External Products and Device types of Products.

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Field Description
Device Problem

The device problem code. The Device Problem codelist is compliant with the FDA DPC code type.

For a medical device problem, select the device problem code.

Select the binoculars icon to search the language corresponding with the medical device usage or start typing for instant search.

Evaluation Method

The device evaluation method code. The Evaluation Method codelist is compliant with the FDA EMC code type.

If the device was evaluated by the manufacturer, select the manufacturer evaluation method code.

Select the binoculars icon to search the language corresponding with the medical device usage or start typing for instant search.

Evaluation Result

The manufacturer evaluation result code. The Evaluation Result codelist is compliant with the FDA ERC code type.

If the device was evaluated by the manufacturer, select the manufacturer evaluation result code.

Select the binoculars icon to search the language corresponding with the medical device usage or start typing for instant search.

Evaluation Conclusion

The manufacturer evaluation conclusion code. The Evaluation Conclusion codelist is compliant with the FDA ECC code type.

If the device was evaluated by the manufacturer, select the manufacturer evaluation conclusion code.

Select the binoculars icon to search the language corresponding with the medical device usage or start typing for instant search.

Blinding Details Section

The Blinding Details section describes the blinding settings active on a Case Product. This section is informational and read-only. By default, this section only displays if the Study associated with the Case is double-blinded. In addition, your Admin must have enabled Product masking selection for Study Products. Manage Case Blinding provides information about unblinding Cases.

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Field Description
Study Blinded

Indicates whether blinding is enabled on the Study associated with the Case Product.

Vault automatically populates this field.

Case Blinded

Indicates whether blinding is enabled on the Case.

Vault automatically populates this field.

Blind Protection

Indicates whether Blind Protection is active for the Study Product. While a Case is blinded, the value in this field is blank. Blind protection becomes active after unblinding the Case.

Vault automatically populates this field.

For more information, see Manage Case Blinding.

Masking

Indicates whether the Study Product is currently blinded, unblinded, or open label.

Vault automatically populates this field.

The values that appear in this field depend on your Admin's configuration.

Also, depending on your Admin's configuration, this field's label may display as Blinded.

For more information, see Enable Product Masking Selection for Study Products.

Registration Section

Use the Registration section to add license and registration details for a Case Product. By default, this section does not appear for blinded Study Products.

If the registration details are already configured in the Product library and you select that Product Registration in the Case Product Details section, Vault automatically populates data in the Registration section.

The following related sections are available only for processing Cases that may be reportable to the PMDA:

  • Case Product Registrations
  • Local Reporting Details
  • PMDA Reportable Products
  • Case Comments

For information on these sections, see Complete Intake and Process Cases for the PMDA.

Field Description
Product

The Product reference to which this Product Registration applies.

Vault automatically populates this field. By default, this field only appears for open or single-blinded Study Products.

Product Type

The Case Product record type.

Vault automatically populates this field, and it is read-only.

Registration Number

Enter the product authorization or application number for the country where the product is marketed.

For U.S. Registrations, ensure that the value you enter in this field adheres to the FDA E2B format requirements for element B.4.k.4.1 (Authorisation / Application Number).

Registration Holder/Applicant

Enter the name of the product license holder or applicant for the product license.

This value is populated from the Registration Holder/Applicant field from the Product Registration record. If this field is blank, this value is snapshot from the Organization field of the Product Registration.

Compounding Type

If the product is a compounded product, specify the type. Start typing for instant search or select the binoculars to browse all available options.

MPID

Enter the Medicinal Product Identifier (MPID) for the product. Note that you can specify only one type of product identifier. Do not specify a MPID if you have entered a PhPID.

MPID Version

Enter the version date or number for the Medicinal Product Identifier (MPID).

Product Registration

If an admin has configured a Product Registration, select the appropriate Product Registration, and then save the page. Fields preconfigured on the Product Registration are automatically populated on the Case Product Registration upon saving. By default, this field only appears for open or single-blinded Study Products.

Product (Coded)

The product name from the product registration.

If the Product Registration Name is available, Vault Safety automatically populates this field using that name. Otherwise, this field is populated with the Product Name. If the Product is part of a blinded Study, the value in this field is blinded.

Registration Country

Select the country where the product is registered and authorized. This field is required when there is a value in the Registration Number field.

Combination Type

If the product is a combination product, select the combination type. This field is used in FDA VAERS reporting.

PhPID

Enter the Pharmaceutical Product Identifier (PhPID). Note that you can specify only one type of product identifier. Do not specify a PhPID if you have entered a MPID.

PhPID Version

Enter the version date or number for the Pharmaceutical Product Identifier (PhPID)

Container Name Part

Enter the product container, if present in the Medicinal Product Name. This field is used in EMA reporting.

Device Name Part

Enter the qualifiers in the name for devices. This field is used in EMA reporting.

Form Name Part

Enter the pharmaceutical form, if present in the Medicinal Product Name. This field is used in EMA reporting.

Invented Name Part

Enter the product name without the trademark or the Marketing Authorization Holder (MAH), or any other descriptor in the product name. This field is used in EMA reporting.

Scientific Name Part

Enter the common product or scientific name without the trademark or the Marketing Authorization Holder (MAH), or any other descriptor in the product name. This field is used in EMA reporting.

Strength Name Part

Enter the strength of the product, if present in the Medicinal Product Name. This field is used in EMA reporting.

Trademark Name Part

Enter the trademark or company, if present in the Medicinal Product Name. This field is used in EMA reporting.

Intended Use Name

Enter the intended use of the product, if present in the Medicinal Product Name without the trademark or the Marketing Authorization Holder (MAH), or any other descriptor in the product name. This field is used in EMA reporting.

Name

Enter the Name of the Case Product Registration.

Blinding Type

Identifies whether a Clinical Trial Study Case Product Registration is blinded.

Vault sets this to one (1) of the following:

  • Blinded
  • Unblinded
  • Open
  • blank (for example, non-Study or External Products)

For more information, see Isolate Blinded Clinical Trial Information.

Registration Country

When the Product Registration is selected, Vault populates the Registration Country from the record in the Product Library .

For more information, see Isolate Blinded Clinical Trial Information.

Product Registration

Select a PMDA Product Registration from the dropdown menu. Product registrations are created when you configure the Product.

Rank

To order Case Products by rank, enter the rank number. Products ranked as 1 correspond to the primary product role. If you change a product to rank 1, Vault updates the rank of the previous primary product to 2. Ranked records appear in descending order on the Case and in generated ICSR documents. This field does not appear on layouts by default and must be added by an Admin to appear.

Due Date

Vault populates this field with the earliest regulatory due date for this Case Product Registration. This is calculated based on the earliest Localized Case Assessment Due Date if one exists. If no Localized Case Assessment associated with this Case Product Registration has a Due Date populated, this field is left bank.

Due in Days

Vault calculates this value for the Case Product Registration based on the most conservative Localized Case Assessment.

Substances Section

Use the Substance section to add Substances under a Case Product. Substance records specify the active substance and strength in the product. By default, this section only appears for External Products and open or single-blinded Study Products.

Add a Substance Record

  1. On the Product record page, expand Substances.
  2. Select Create.
  3. Complete the Create Case Product Substance page.
  4. Select Save.

Case Product Substance Fields

alt-text

Field Description
Case

Reference to the grandparent Case.

Vault automatically populates this field.

Case Product

Reference to the parent Case Product.

Vault automatically populates this field.

Substance Name

Enter the substance name, as reported.

Strength

The substance strength. If the strength is a range, enter the lowest number in the range.

In the first field, enter the number. In the second field, select the Unit of Measurement.

TermID

Enter the substance Term ID.

TermID Version

Enter the substance Term ID Version or Version Date.

Blinding Type

Identifies whether a Clinical Trial Study Case Product Substance is blinded.

Vault sets this to one (1) of the following:

  • Blinded
  • Unblinded
  • Open
  • blank (for example, non-Study or External Products)

For more information, see Isolate Blinded Clinical Trial Information.

Blinded Reference ID

This field is always blank.

Adverse Events Section

Use the Adverse Events section to add Case Adverse Events with details of each adverse event. For Cases with SAEs transferred from the Safety-EDC Vault Connection, you can run the Add Relevant Subject Information action to automatically add the applicable subject information to the Case. For more information, see About the Safety-EDC Vault Connection.

case-adverse-event-section

Add a Case Adverse Event Record

  1. On the Case page, expand the Adverse Events section.
  2. Select Create.
  3. Complete the Create Adverse Event page.
  4. Select Save.

Case Adverse Event Fields

The Case Adverse Event layout provides fields in the Details and Hospitalization/Treatment sections.

Case Adverse Event Details Section

Adverse Events Details Section

Field Description
Case

Reference link to the Case.

Vault automatically populates this field.

Primary

Indicates the primary adverse event for this report.

Select Yes if the adverse event is the reason for reporting the case or is most likely linked to the suspect product.

Rank

To order Case Adverse Events by rank, enter the rank number.

Adverse events ranked as 1 correspond to the primary adverse event role.

If you change an adverse event to rank 1, Vault updates the rank of the previous primary adverse event to 2. Ranked records appear in ascending order on the Case and in generated ICSR documents.

Seriousness

The level of impact the adverse event had on the patient. You can enter multiple values in this field.

Select one or more seriousness criteria to describe the level of impact the adverse event had on the patient. If the event is not serious, do not select a value in this field.

CTCAE Grade

The Common Terminology Criteria for Adverse Events (CTCAE) grade for adverse events affecting cancer patients.

For adverse events affecting cancer patients, select the CTCAE grade from the drop-down menu.

Event (Reported)

Description of the medical event, as reported by the primary source.

Enter the reported term in the text field, then use the Auto-Code button to automatically match and code the MedDRA term. Alternatively, use the binoculars icon to open the MedDRA browser.

The language dropdown menu shows the MedDRA dictionary language being used. English is selected by default.

For more information, see Code MedDRA Terms.

Event (Reported) - Language

The language that the primary source reported the event description in, if other than English.

Use the binoculars icon to search for the language corresponding with the adverse event or enter the language manually.

Event Country

Select the country where the adverse event occurred. Use the binoculars icon to search for the country or start typing for instant search.

Onset

The date on which the adverse event or reaction started.

Use the Calendar pop-up tool to select a date or enter the date manually.

If the source report omits this information, use the Reason Omitted field to describe why the information is unavailable.

If you select "Masked" as the Reason Omitted, the Reaction Onset is masked on the CIOMS I form. For more information, see CIOMS I Generation Data Mapping.

Cessation

The date when the adverse event ended.

Use the Calendar pop-up tool to select a date or enter the date manually.

If the source report omits this information, use the Reason Omitted field to describe why the information is unavailable.

Duration

The overall duration of time that the patient experienced the adverse event.

Auto-Calculation

Vault automatically calculates this field once you save the Case Adverse Event, based on the time interval between the following dates:

  • Onset
  • Cessation

Vault recalculates and updates this field any time the above field values are updated. If you manually enter a value after the auto-calculation, Vault retains the manually entered value. If you manually enter a value and then edit a field used in the auto-calculation, Vault will re-calculate and override the manually entered value, assuming there is sufficient data for calculation.

You can also disable auto-calculation for this field to retain the manually entered value. See Manage Auto-Calculation Override for more detail.

Outcome

Select the outcome of the adverse event:

  • fatal: Select this option when the patient's death is suspected to be related to the adverse event.
  • not recovered/not resolved/ongoing: Select this option when the patient had not recovered from the adverse event or for an irreversible congenital anomaly.
  • recovered/resolved: Select this option if the patient has fully recuperated from the adverse event.
  • recovered/resolved with sequelae: Select this option for an irreversible medical condition.
  • recovering/resolving: Select this option if the patient is recuperating from the adverse event.
  • unknown: Select this option when the outcome is unknown.

HCP Confirmed

Indicates whether a healthcare professional confirmed the adverse event.

Vault automatically populates this field for the primary adverse event, based on the Reporter Qualification specified on the initial Inbox Item. Otherwise, you can enter the value manually.

Symptom/Diagnosis

Indicates whether the adverse event is a symptom or a diagnosis.

To designate the adverse event as a symptom or a diagnosis, select an option from the list.

Diagnosis

To associate an adverse event symptom to a diagnosis, select the Case Diagnosis.

To appear in this list, a medical reviewer must have already entered the Case Diagnosis. The Case Diagnoses section provides instructions.

Watchlist Tags

Vault automatically populates this field when a Case Adverse Event matches one or more configured watchlists.

For more information, see How Case Watchlist Tags and DMEs are Assigned.

DME

Indicates if the adverse event MedDRA PT matches a Designated Medical Event (DME).

Vault automatically populates this field when the adverse event MedDRA PT matches a Designated Medical Event (DME). The suspect product must be registered in the European Union for the adverse event to qualify as a DME.

For more information, see How Case Watchlist Tags and DMEs are Assigned.

Case Adverse Event Hospitalization/Treatment Section

Case Adverse Event Hospitalization Section

Field Description
Hospitalization

Select the patient outcome with respect to hospitalization. This is required for FDA VAERS reporting when the Case Adverse Event Seriousness is set to "Caused / Prolonged Hospitalization".

  • Hospitalization (FDA.E.i.3.2c.1)
  • Prolongation of Hospitalization (FDA.E.i.3.2c.2)

Evaluated/Treated At

Select the type of facility the patient was evaluated or treated at:

  • Doctor/healthcare professional Office (FDA.E.i.3.3a)
  • Emergency Department or urgent care (FDA.E.i.3.3b)
  • Blank (FDA.E.i.3.2g)

This field is used in FDA VAERS reporting.

If the source report omits this information, use the Reason Omitted field to describe why the information is unavailable.

Hospital Admission Date

The date the patient was admitted into the hospital.

Use the calendar pop-up tool or enter the date manually.

Hospital Discharge Date

The patient was discharged from the hospital.

Use the calendar pop-up tool or enter the date manually.

Days Hospitalized

Enter the number of days the patient was hospitalized. This field is used in FDA VAERS reporting.

If the source report omits this information, use the Reason Omitted field to describe why the information is unavailable.

Hospital Name

Enter the name of the hospital. This field is used in FDA VAERS reporting.

If the source report omits this information, use the Reason Omitted field to describe why the information is unavailable.

Hospital City

Enter the city where the hospital is located. This field is used in FDA VAERS reporting.

If the source report omits this information, use the Reason Omitted field to describe why the information is unavailable.

Hospital State

Select the state where the hospital is located. This field is used in FDA VAERS reporting.

If the source report omits this information, use the Reason Omitted field to describe why the information is unavailable.

Diagnoses Section

Use the Diagnoses section to combine signs and symptoms that were reported into a single Case Diagnosis, if required.

By default, the Diagnoses section does not appear until the Case is in the Medical Review state.

Add a Case Diagnosis Record

  1. On the Case page, expand the Diagnoses section. If the section is not displayed, verify that the Case is in the Medical Review state and that you are assigned the Medical Reviewer user role.
  2. Select Create. The Create Case Diagnosis page appears.
  3. Enter the diagnosis, and then select Save.

Result

The diagnosis is added to the Case under Diagnoses.

Case Diagnosis Fields

Case Diagnosis Fields

Field Description
Case

Reference link to the Case.

Name (MedDRA)

The MedDRA term for the case diagnosis.

Enter the term in the text field, then use the Auto-Code button to automatically match and code the MedDRA term. Alternatively, use the binoculars icon to open the MedDRA browser.

For more information, see Code MedDRA Terms.

Name (Reported)

Captures a text description of the diagnosis or reclassification of the adverse event.

This field is not currently supported for E2B import or export or any type of report generation.

This field does not appear on layouts by default and must be added by your Admin.

Assessments Section

The Assessments section displays the assessed relationship between Adverse Events and Suspect or Interacting Products. For any Adverse Event and Product pair, there can be only one (1) Case Assessment. For each Case Assessment, Vault generates two (2) Case Assessment Results.

By default, Vault generates Case Assessments for the following pairs:

  • All serious Adverse Events paired with Case Products that have a Drug Role of Suspect or Interacting
  • Primary non-serious Adverse Events paired with primary Case Products that have a Drug Role of Suspect or Interacting
  • Depending on your Admin’s configuration of Drug Roles that are considered suspect, all serious Adverse Events and primary non-serious Adverse Events paired with primary Case Products that have a Drug Role of Drug Not Administered

For more information on the ways to generate Assessments, see Generate Assessments.

Add a Case Assessment Record

While Vault automatically generates Case Assessments, you may need to add an assessment manually, for example, if you accidentally delete a system-generated assessment.

  1. On the Case, expand the Case Assessments section.
  2. Under Case Assessments, select Create.
    The Create Case Assessment page appears.
  3. In the Case Product field, select the suspect product.
  4. In the Case Adverse Event field, select the relevant adverse event.
  5. Enter the assessment details and results.

After you finish, enter the Case Assessment Result.

Case Assessment Details Fields

case-assessment

Field Description
Case

Reference link to the Case.

Vault automatically populates this field.

Product

Reference link to the Case Product.

Vault automatically populates this field with the Case Product this assessment is evaluating.

Event (LLT)

Reference link to the Case Adverse Event.

Vault automatically populates this field with the Case Adverse Event this assessment is evaluating.

Expected

Whether the associated Case Adverse Event matches to an Expected term on Datasheets associated with the suspect Case Product or associated Study or Study Products. Any MedDRA Lower Level Term is considered a match if it is listed on or falls under the hierarchy of the term on the Datasheet.

If your Admin has configured Datasheets, Vault populates this field based on the expected reactions listed on the Datasheets. You can select a different option to override Vault-calculated value or to enter the value manually. Vault uses this value from the primary Case Assessment to populate the Case Expectedness field.

For more information, see Manage Datasheets and Auto-Expectedness.

Expected (status)

How the Expected field was populated, whether system-calculated or with a manual override. By default, users in the Intake and Data Entry roles cannot edit this field.

Vault automatically populates this field.

Listedness (Core)

Whether the associated Case Adverse Event matches to a term on the Datasheet for the Study or Product. Any MedDRA Lower Level Term is considered a match if it is listed on or falls under the hierarchy of the term on the Core Datasheet.

If your Admin has configured Datasheets, Vault populates this field based on the expected reactions listed on the Datasheets. You can select a different option to override Vault-calculated value or to enter the value manually. Vault uses this value from the primary Case Assessment to populate the Case Listedness (Core) field.

For more information, see Manage Datasheets and Auto-Expectedness.

Listedness (status)

How the Listedness (Core) field was populated, whether system-calculated or with a manual override. By default, users in the Intake and Data Entry roles cannot edit this field.

Vault automatically populates this field.

Reaction Recurrence

Select the option that best describes whether the adverse event recurred.

Note that the option "no - n/a (no rechallenge was done, recurrence is not applicable)" is equivalent to a dechallenge. You can capture the dechallenge details, such as positive or negative, in the case narrative.

First Dose Latency

The time interval between the first administered dose of the product and when the adverse event started.

Auto-Calculation

Vault automatically calculates the first dose latency, based on the time interval between the following dates:

  • The First Admin Date field on the Case Product Dosage
  • The Onset field on the Case Adverse Event

Vault recalculates and updates this field any time the Onset or First Admin Date values are updated. If you manually enter a value after the auto-calculation, Vault retains the manually entered value. If you manually enter a value and then edit a field used in the auto-calculation, Vault will re-calculate and override the manually entered value, assuming there is sufficient data for calculation.

You can also disable auto-calculation for this field to retain the manually entered value. See Manage Auto-Calculation Override for more detail.

For more information, see How Dose Latency is Calculated.

Last Dose Latency

The time interval between the last administered dose of the product and when the adverse event started.

Auto-Calculation

Vault automatically calculates the last dose latency, based on the time interval between the following dates:

  • The Last Admin Date field on the Case Product Dosage
  • The Onset field on the Case Adverse Event

Vault recalculates and updates this field any time the Onset or Last Admin Date values are updated. If you manually enter a value after the auto-calculation, Vault retains the manually entered value. If you manually enter a value and then edit a field used in the auto-calculation, Vault will re-calculate and override the manually entered value, assuming there is sufficient data for calculation.

You can also disable auto-calculation for this field to retain the manually entered value. See Manage Auto-Calculation Override for more detail.

For more information, see How Dose Latency is Calculated.

Rank

Ranked assessments are listed in ascending order on the Case.

To order the list of assessments by rank, enter the rank number. The rank of 1 is reserved for the assessment on the primary adverse event and primary product.

Assessment Tag

Vault automatically tags Case Assessments as SUSAR or SAE when the appropriate criteria is met:

  • SUSAR: When a Study Case Assessment for a Serious, Unexpected Adverse Event paired with a Suspect, Interacting, or Drug Not Administered company Product is assessed as related:
    1. The Case Product associated with the Assessment must be Suspect, Interacting, or Drug Not Administered. (The Case Product > Drug Role (drug_role__v) field is set to Suspect, Interacting, or Drug Not Administered.)
    2. The Case Adverse Event associated with the Assessment must be Serious. (A value is entered in the Case Adverse Event > Seriousness (seriousness__v) field.)
    3. The Expectedness field on the Assessment is set to No or is blank.
    4. The Assessment has at least one Assessment Result with the Causality Established field set to Yes.
  • SAE: When a Case Assessment contains a Serious Adverse Event paired with a Suspect, Interacting, or Drug Not Administered company Product:
    1. The Case Product associated with the Assessment must be Suspect, Interacting, or Drug Not Administered. (The Case Product > Drug Role (drug_role__v) field is set to Suspect, Interacting, or Drug Not Administered.)
    2. The Case Product associated with the Assessment must be selected from the Product Library (for example, Case Product > Product is selected) or a Study Product.
    3. The Case Adverse Event associated with the Assessment must be Serious. (A value is entered in the Case Adverse Event > Seriousness (seriousness__v) field.)

If neither of the above criteria are met, then the Assessment Tags field is left blank.

Blinding Type

Identifies whether a Clinical Trial Study Case Assessment is blinded.

This can be set to one (1) of the following:

  • Blinded
  • Unblinded
  • Open
  • blank (for example, non-Study or External Products)

For more information, see Isolate Blinded Clinical Trial Information.

Blinded Reference

For unblinded Clinical Trial Study Case Assessment records, links to the associated blinded record.

For more information, see Isolate Blinded Clinical Trial Information.

Expectedness Section

Vault generates Expectedness records under Case Assessments. Expectedness records identify whether Case Adverse Events (MedDRA terms) match to a term on a Product (Core or Local), Product Family, Study, or Study Product Datasheet. Datasheet terms may have specified demographics, such as sex and age range, that are also evaluated when generating Expectedness. Any MedDRA Lower Level Term is considered a match if it is listed on or falls under the hierarchy of the term on the Datasheet.

An Expectedness record is generated for each of the associated Datasheets. Vault evaluates expectedness upon Case creation and re-evaluated any time any of the following related records and fields are updated:

  • Case Assessment
  • Case Adverse Event
  • Case Product
  • Case Patient Sex
  • Case Patient Age (including Date of Birth, Age at Onset, or Age Group)

If overridden or manually set, Vault does not re-evaluate Expectedness after these updates.

If the Generate Assessments feature is enabled, Expectedness is also evaluated when Assessments are auto-generated or the Generate Assessments user action is activated. Where Expectedness records don’t exist, Vault generates them.

Field Description
Name

The name of the Expectedness record.

Vault automatically populates this field for system-generated Expectedness.

Datasheet

A link to the Datasheet configured in Business Admin.

To view the Datasheet record, select the link.

For more information, see Manage Datasheets and Auto-Expectedness.

Datasheet Document

The associated datasheet document from the Vault Library.

To view the datasheet Vault document, select the link.

Country

For Local Datasheets, the country to which the datasheet applies. When evaluating reporting rules, Vault uses Local Datasheets within the jurisdiction of the target agency to evaluate the Expectedness rule parameter.

Vault automatically populates this field for system-generated Expectedness.

For more information, see Reporting Rule Parameter Reference.

Expected

Indicates whether the Case Adverse Event MedDRA matches to a term on the referenced Datasheet. Any MedDRA Lower Level Term is considered a match if it is listed on or falls under the hierarchy of the term on the Datasheet.

Vault automatically populates this field for system-generated Expectedness.

For more information, see Manage Datasheets and Auto-Expectedness.

Expected (status)

How the Expected field was populated, whether system-calculated or with a manual override.

Vault automatically populates this field for system-generated Expectedness.

Based On

For Clinical Trial Study Cases, identifies whether Vault calculated expectedness based on the Onset date of Adverse Events or the New Info Date on the Case.

For more information, see how Vault calculates expectedness for Clinical Trial Study Cases based on Agency settings in How Case Assessment Expectedness is Generated.

Expectedness Justification

When Vault evaluates the Expected value for an Adverse Event based on the applicable Datasheet, Vault populates the value from the Expectedness Justification field for the Adverse Event on the Datasheet. You can enter or edit the value in this field, using up to 1,000 characters.

For all Cases reportable to Localizations that do not have Localized Assessments for Case Product Registrations in the Assessment Generation field, Vault maps this value to related Localized Case Assessments.

Blinding Type

Identifies whether a Clinical Trial Study Case Assessment Expectedness is blinded.

This can be set to one (1) of the following:

  • Blinded
  • Unblinded
  • Open
  • blank (for example, non-Study or External Products)

For more information, see Isolate Blinded Clinical Trial Information.

Blinded Reference ID

For unblinded Clinical Trial Study Case Product Assessment Expectedness records, references the associated blinded record.

For more information, see Isolate Blinded Clinical Trial Information.

Assessment Results Section

Use the Assessment Results section to enter the assessed relationship between the adverse event and product pair from individual sources.

System-Generated Case Assessment Results

When a Case Assessment is created (either system-generated or user-created), Vault generates two child Case Assessment Results as placeholders: one for the company and one for the primary reporter.

Vault assigns the Source Type for auto-generated Case Assessment Results using the logic described in the following sections. The Source Type field refers to the Case Assessment Source Controlled Vocabulary.

Clinical Trial Cases

For Clinical Trial Cases and for Study Cases where the Study Type is blank, Vault generates Case Assessment Results with the following Source Types:

Case Assessment Result Placeholder Source Type E2B Code1
Company Sponsor 2
Reporter Investigator 1
  1. E2B Code refers to the value in the e2b_code__v field on the Controlled Vocabulary corresponding to the Source Type field.

Postmarket Cases

For Spontaneous and Postmarket Study Cases, Vault generates Case Assessment Results with the Source Types shown in the table below:

Case Assessment Result Placeholder Qualified HCP?1 Source Type E2B Code2
Company n/a Market Authorization Holder (MAH) 4
Reporter Yes Health Care Professional 5
Reporter No Non-Health Care Professional 6
  1. Whether the Qualification selected on the primary Reporter type of Case Contact corresponds to a Qualification Controlled Vocabulary where Qualified HCP is Yes.
  2. E2B Code refers to the value in the e2b_code__v field on the Controlled Vocabulary corresponding to the Source Type field.

Enter Case Assessment Results

  1. On the Case, expand Case Assessment Results.
  2. Open the Case Assessment Result that you want to edit, or select Create to add a new Assessment Result.
  3. Complete the fields on the Case Assessment Result page.
  4. Select Save.

case-assessment

Case Assessment Result Fields

Case Assessment Result Details Fields

Field Description
Case

Reference link to the Case.

Vault automatically populates this field.

Case Assessment

Reference link to the Case Assessment.

Vault automatically populates this field.

Source Type

Description of the source of the assessment, such as Sponsor, Investigator, or Health Care Professional.

For auto-generated Case Assessment Results, Vault automatically populates the Source Type as follows:

  • Company's Assessment: The Source Type is set to Sponsor or MAH.
  • Reporter's Assessment: The Source Type is set to one of the following, based on the Report Type and the Reporter Qualification specified on the primary Reporter-type Case Contact:
    • Investigator
    • Health Care Professional
    • Non-Health Care Professional

For more information, see About Generating Assessments.

Source (text)

If you cannot capture the source using an option from the Source Type list, use this field to enter a free text description of the source.

Method of Assessment

Select the option that best describes the method of assessing the case.

Method (text)

If you cannot capture the assessment method using an option from the Method of Assessment list, use this field to enter a free text description of the method.

Assessment Result

Describes the result of the Case Assessment. Vault may populate this field or you can select an option.

Assessment Result (Override)

(Optional) An Admin must add this field to the Case layout.
If you select a value for this field, Vault uses this value instead of the Assessment Result value when generating an E2B document or a CIOMS I Transmission or preview. Contact Veeva Support to request this feature be made available in your Vault.

Result (text)

If you cannot capture the assessment result using an option from the Assessment Result list, use this field to enter a free text description of the result.

Causality Established

Indicates whether the adverse event causality has been established with respect to the suspect product.

The value in this field from the primary Case Assessment Results to populate the Case Relatedness. If this is set to Yes on any primary Case Assessment Result, the Case Relatedness is set to Yes.

Vault automatically populates this field.

For more information, see How Case Relatedness is Calculated.

Blinding Type

Identifies whether a Clinical Trial Study Case Assessment Result is blinded.

This can be set to one (1) of the following:

  • Blinded
  • Unblinded
  • Open
  • blank (for example, non-Study or External Products)

For more information, see Isolate Blinded Clinical Trial Information.

Blinded Reference ID

For unblinded Clinical Trial Study Case Product Assessment Result records, references the associated blinded record.

For more information, see Isolate Blinded Clinical Trial Information.

Causes of Death Section

Use the Causes of Death section to enter the details about the reported and autopsy-determined causes of death.

The Causes of Death section appears if at least one of the following conditions are met:

  • The Date of Death field has a value
  • A Seriousness field value on an Adverse Event for the Case contains “Results in Death”

Add a Cause of Death Record

  1. On the Case, expand Causes of Death.
  2. Select Create.
  3. In the Create Case Cause of Death Type window, select one of the following options:
    • Reported Cause of Death
    • Autopsy-Determined Cause of Death
  4. Select Continue.
  5. Specify the Case Cause of Death fields.
  6. Select Save.

Result

When you save the Cause of Death record, the Causes of Death section is updated with the cause of death and a link to the record.

Cause of Death Fields

Causes of Death Section

Field Description
Case

Reference link to the Case.

Vault automatically populates this field.

Cause (Reported)

The reported term and MedDRA term for the cause of death.

Enter the reported term in the text field, then use the Auto-Code button to automatically match and code the MedDRA term.

Alternatively, use the binoculars icon to open the MedDRA browser

For more information, see Code MedDRA Terms.

Medical History & Concurrent Conditions Section

Use the Medical History & Concurrent Conditions section to add a Medical History record for each event reported in the patient’s medical history.

Add a Medical History Record

  1. On the Case page, under Medical History, Select Create.
  2. On the Create Case Medical History page, enter the medical history event details.
  3. Select Save.

Result

When you save the record, the Case Medical History & Concurrent Conditions section is updated with the record and link.

Medical History & Concurrent Conditions Fields

Case Medical History Section

Field Description
Case

Reference link to the Case.

Vault automatically populates this field.

Condition/Procedure

Enter the reported term in the text field, then use the Auto-Code button to automatically match and code the MedDRA term.

Alternatively, use the binoculars icon to open the MedDRA browser

For more information, see Code MedDRA Terms.

Start Date

Use the calendar pop-up tool to select a date or enter the date manually.

The date when the medical condition started.

If the source report omits this information, use the Reason Omitted field to describe why the information is unavailable.

Continuing

Select Yes or No to indicate whether the medical condition is currently ongoing.

If the source report omits this information, use the Reason Omitted field to describe why the information is unavailable.

End Date

The date when the medical condition stopped.

Use the calendar pop-up tool to select a date or enter the date manually.

If the source report omits this information, use the Reason Omitted field to describe why the information is unavailable.

Family History

Select Yes or No to indicate whether another family member experienced the same medical condition.

Illness at Vaccination?

Select Yes or No to indicate whether the illness, condition, or symptom was present at or about the time of vaccination.

Comments

Enter any additional relevant information about the medical condition.

Drug History Section

Create a Drug History record for each product reported in the patient’s drug history.

Add a Drug History Record

  1. On the Case page, expand Drug History.
  2. Select Create.
  3. On the Create Case Drug History page, enter the drug history details.
  4. Select Save.

Result

When you save the Drug History record, the case Drug History section is updated with the record and link.

Drug History Fields

Field Description
Case

Reference link to the Case.

Vault automatically populates this field.

Drug Name (Reported)

Enter the name of the product, as reported by the source.

If the source report omits this information, use the Reason Omitted field to describe why the information is unavailable.

WHODrug

Product code from the WHODrug dictionary.

After entering the reported drug name, select Search WHODrug to automatically populate the search query. Browse and select the appropriate product code using the WHODrug search window.

For more information, see Code WHODrug Products.

MPID

Medicinal Product Identifier (MPID) for the product. This field appears after coding the WHODrug product code.

This field is automatically populated based on the selection from the WHODrug dictionary.

Version

The WHODrug version for the MPID. This field appears after coding the WHODrug product code.

This field is automatically populated based on the selection from the WHODrug dictionary.

Start Date

Use the calendar pop-up tool to select a date or enter the date manually.

The date and time when the product was first administered.

If the source report omits this information, use the Reason Omitted field to describe why the information is unavailable.

End Date

The date and time when the product was last administered.

Use the calendar pop-up tool to select a date or enter the date manually.

If the source report omits this information, use the Reason Omitted field to describe why the information is unavailable.

Indication (LLT)

The MedDRA LLT for the drug history product use indication.

Enter the term in the text field, then use the Auto-Code button to automatically match and code the MedDRA term. Alternatively, use the binoculars icon to open the MedDRA browser.

For more information, see Code MedDRA Terms.

Indication (Reported)

Captures a text description of the drug history product use indication.

This field is not currently supported for E2B import or export or any type of report generation.

This field does not appear on layouts by default and must be added by your Admin.

Reaction (LLT)

The MedDRA LLT for the reaction to the drug history product.

Enter the term in the text field, then use the Auto-Code button to automatically match and code the MedDRA term. Alternatively, use the binoculars icon to open the MedDRA browser.

For more information, see Code MedDRA Terms.

Reaction (Reported)

Captures a text description of the reaction to the drug history product.

This field is not currently supported for E2B import or export or any type of report generation.

This field does not appear on layouts by default and must be added by your Admin.

Age at Vaccination

The age of the patient at the time of vaccination. This field is used in FDA VAERS reporting.

Vault recalculates and updates this field any time a field used to calculate this value is updated. If you manually enter a value after the auto-calculation, Vault retains the manually entered value. If you manually enter a value and then edit a field used in the auto-calculation, Vault will re-calculate and override the manually entered value, assuming there is sufficient data for calculation.

You can also disable auto-calculation for this field to retain the manually entered value. See Manage Auto-Calculation Override for more detail.

Auto-Calculation

Vault automatically calculates this field for vaccine-type products. The age at vaccination is calculated using the time interval between the following dates:

  1. The Case Date of Birth field
  2. The Case Drug History Start Date field
    The Product Type field on the Drug History record must be set to Vaccine. If you do not see this field, an Admin must add it to the layout.

Invented Name Part

Enter the product name without the trademark or the Marketing Authorization Holder (MAH), or any other descriptor in the product name. This field is used in EMA reporting.

Scientific Name Part

Enter the common product or scientific name without the trademark or the Marketing Authorization Holder (MAH), or any other descriptor in the product name. This field is used in EMA reporting.

Trademark Name Part

Enter the trademark or company, if present in the Medicinal Product Name. This field is used in EMA reporting.

Strength Name Part

Enter the strength of the product, if present in the Medicinal Product Name. This field is used in EMA reporting.

Form Name Part

Enter the pharmaceutical form, if present in the Medicinal Product Name. This field is used in EMA reporting.

Container Name Part

Enter the product container, if present in the Medicinal Product Name. This field is used in EMA reporting.

Device Name Part

Enter the qualifiers in the name for devices. This field is used in EMA reporting.

Intended Use Name Part

Enter the intended use of the product, if present in the Medicinal Product Name without the trademark or the Marketing Authorization Holder (MAH), or any other descriptor in the product name. This field is used in EMA reporting.

Add a Drug History Substance Record

Drug History Substance records capture data for EMA E2B section D.8.r.EU Substance / Specified Substance Identifier and Strength.

Your Admin may need to configure layouts to enable Case Drug History Substance data entry.

  1. On the Case Drug History page, expand Drug History Substances.
  2. Select Create.
  3. On the Create Case Drug Substance History page, enter the drug history substance details.
  4. Select Save.

Result

When you save the Drug History record, the case Drug History Substances section is updated with the record and link.

Drug History Substance Fields

Field Description
Case

Reference link to the grandparent Case.

Vault automatically populates this field.

Case Drug History

Reference link to the parent Case Drug History.

Vault automatically populates this field.

Strength (Number)

The substance strength. If the strength is a range, enter the lowest number in the range.

Strength (Unit)

Select the substance unit of measurement.

Substance Name

Enter the substance name, as reported.

TermID

Enter the substance Term ID.

TermID Version

Enter the substance Term ID Version or Version Date.

Test Results Section

Create a Case Test Result record for each test result.

Add a Case Test Result Record

  1. On the Case page, expand Lab Test Results.
  2. Select Create.
  3. Complete the Create Case Test Result page.
  4. Select Save.

Result

The Case Test Result is added to the Case.

lab-test-results-section

Case Test Result Fields

case test result

Field Description
Case

Reference link to the Case.

Vault populates this field.

Test Name (Reported)

The reported term and MedDRA term for the test performed.

Enter the reported name of the test or procedure in the text field, and then use the Auto-Code button to automatically match and code the MedDRA term. Alternatively, use the binoculars icon to open the MedDRA browser.

For more information, see Code MedDRA Terms.

Test Date

Date and time (if available) when the test or procedure was performed.

Use the calendar pop-up tool to select a date or enter the date manually.

If the source report omits this information, use the Reason Omitted field to describe why the information is unavailable.

Test Result

Optionally, enter a qualifier, such as "Less than" (<). In the Number field, enter the value for the test result. In the Unit field, select the test result unit of measurement from the picklist, or use a custom entry.

When you enter a custom unit of measurement, the unit also appears in the Result (Unit) Text field.

Result (Text)

Enter a description of the test result.

Result (Unit) Text

Enter a description of the test result unit.

This field is automatically populated if a custom unit of measurement is entered in the Test Result (Unit) field.

Result (Code)

Code to describe the test result.

Select one of the following options from the picklist:

  • Positive
  • Negative
  • Borderline
  • Inconclusive

Normal High Value

Enter the highest value in the normal range for the test. This value is usually published by the laboratory providing the test result.

Normal Low Value

Enter the lowest value in the normal range for the test. This value is usually published by the laboratory providing the test result.

Comments

Enter any relevant comments from the reporter about the test result.

More Information Available

Select Yes or No to indicate whether the sender has more information about the test result.

Narrative Section

Use the Narrative section on the Case to compose the case narrative and capture additional comments from both the reporter and sender.

When a Case is created, Vault automatically generates a narrative document using the appropriate narrative template.

Narrative Section

Field Description
Case Narrative

Vault automatically populates this field with a link to the narrative document, which is generated when you create the Case. To open the narrative document, select the link.

For more information, see Compose a Case Narrative.

Narrative Preview

This field is read-only and automatically updated with a text excerpt of the narrative document, up to 32,000 characters. This field shows a preview of the narrative that will be populated in generated regulatory reports. To update the narrative, edit the narrative document.

When blind protection is active, this field is prepended with [Blind Protection].

Company Comments

Enter the company's assessment of the case, which can be used to describe disagreement with, or alternatives to the reporter's assessment.

Reporter's Comments

Enter the reporter's comments on the causality assessment, diagnosis, or other relevant topics.

Study Section

When the Report Type of the Case is Study, the Study section appears on the layout for entering information about the Study the patient is enrolled in.

If a Study was selected on the initial Inbox Item, the study fields are automatically populated with any available Study data configured in Business Admin.

Field Description
Study

Select the Study associated with the report. Once a Study is selected, the study name fields are hidden and the available field values and Registrations from the Study are automatically added to the Case upon saving. Otherwise, you can enter the study information manually.

For more information, see Manage Studies.

Study Blinded

Vault populates this field according to the Blinded setting on the selected Study. This field is read-only.

Study Type

The type of study for which the product was administered. Depending on your Vault's configuration, this field may only appear when the Report Type is Study.

If this field is preconfigured in the associated Study, Vault automatically populates this field. Otherwise, you can manually select the value.

The following options are available by default:

  • Clinical Trial: This option corresponds to E2B code 1 for data element C.5.4.
  • Individual Patient Use: For example, compassionate use, named patient basis. This option corresponds to E2B code 2 for data element C.5.4.
  • Other Study: For example, pharmacoepidemiology, pharmacoeconomics, intensive monitoring. This option corresponds to E2B code 3 for data element C.5.4.

Study Number (Reported)

Enter the study number for the Study that the Case is associated with.

If the source report omits this information, use the Reason Omitted field to describe why the information is unavailable.

Study Name

If entering the study information manually, enter the name of the study.

Study Name (Continued)

If entering the study information manually and the study name exceeds the character limit in the Study Name field, you can enter additional characters in this field.

Study Name (reason omitted)

If entering the study information manually and the study name is masked or unavailable, select the reason why the study name is unavailable.

Unblinded By

This field appears once the Case is unblinded.

Select the option that best describes who unblinded the Case. By default you can either select Sponsor or Investigator.

Unblinded Reason

This field appears once the Case is unblinded.

Enter the reason the Case was unblinded.

Unblinded Date

This field appears once the Case is unblinded.

Enter the date when the Case was unblinded.

Study Registrations Section

When the Report Type of the Case is Study, the Study Registrations section appears on the layout for entering registration information about the Study the patient is enrolled in.

When you select a Study in the Study section and save the page, Vault automatically adds each registration configured under the associated Study in Business Admin.

Add a Study Registration Record

  1. On a Case, expand Case Study Registrations.
  2. Select Create.
  3. Complete the Create Case Study Registration page.
  4. Select Save.

Study Registration Fields

Study Registrations Section

Field Description
Case

Reference link to the Case.

Vault automatically populates this field.

Registration Number

Manually enter the study registration number as assigned by the reporting country or region. For trials registered in the EU, use this field to enter the EudraCT number.

If the source report omits this information, use the Reason Omitted field to describe why the information is unavailable.

Registration Country

The country where the study is registered.

Select the country from the list or start typing for instant search.

If the source report omits this information, use the Reason Omitted field to describe why the information is unavailable.

Vault may update or populate Case Study Registration data in the following scenarios:

  • When you create a follow-up Case from a Case or non-E2B-imported Inbox Item, Vault populates the Study Registrations section on the follow-up Case with the latest registration data from the Study library.
  • When you merge an E2B-imported Inbox Item to an in-flight Case or promote it to a follow-up Case, Vault snapshots the Inbox Item’s Study registration data to the Study Registrations section on the in-flight Case.
  • After automated Case promotion for Inbox Items imported from E2B or JSON, Vault populates the Study Registrations section on the follow-up Case with the Inbox Item Study registration data.

Linked Cases Section

Use the Linked Cases section to link to each related Case.

Add a Case Relationship Record

  1. On the Case page, expand Linked Cases.
  2. Select Create.
  3. Complete the Create Case Relationship page.
  4. Select Save.

Case Relationship Fields

Linked Cases Section

Field Description
Case

Reference link to the Case.

Vault automatically populates this field.

Related Case

Select the related Case.

Related Case Identifier

Enter the identification number for the report which is linked to this report.

Retransmit

This field controls whether the linked report is included in outbound E2B transmissions for this Case.

To populate the related Case UID in E2B transmissions, select Yes.

Reference Numbers Section

Use the Reference Numbers section to enter Case Identifiers, which contain identification codes for the report from systems outside of Vault.

Add a Case Identifier Record

  1. On the Case page, expand Reference Numbers.
  2. Select Create.
  3. Complete the Create Case Identifier window.
  4. Select Save.

Case Identifier Fields

Reference Numbers Section

Field Description
Case

Reference link to the Case.

Vault automatically populates this field.

Case Identifier

(Required) If this report was previously exchanged, or is currently being exchanged, using a different identifier, enter the identification number.

For example, you can use this field for the following use cases:

  • Capture a case identifier from a legacy system.
  • Capture the ID for a report transmitted from another manufacturer who is not the license holder for the suspect product.
Source

Enter the name of the organization that associates the report with this identifier.

Type

Select one of the following options:

For example, you can use this field for the following use cases:

  • To include the Case Identifier and Source fields on the E2B Transmission document upon E2B export, leave this field blank or select E2B Re-Transmittable.
  • Otherwise, select Non-Transmittable.

Your Admin can configure additional Case Identifier Types.

Documents Section

Use the Documents section to add and manage documents linked to the Case, including the source report, narrative, attachments, literature, and other relevant documents.

Documents Section

For more information about to add a document to a record, such as a Case, see Managing Object Records.

E2B Transmission Document Setup

To be included in E2B transmissions, Case documents must be classified with the Case › Source › Attachment or Case › Source › Literature document type. In addition, the document Retransmit field value must be Yes.

When sending FDA E2B(R2) or FDA E2B(R3) Transmissions through an AS2 Connection for Cases with over-the-counter (OTC) drugs, you can also attach OTC carton images. Files must be classified with the Case > Source > Attachment document type and the Attachment Type field value must be FDA Carton Attachment.

Add a Case Attachment or Literature Document

  1. Go to the Case to which you want to add a document.
  2. Expand Documents.
  3. Select Add.
  4. Use one of the following methods to add the document:
    • If the document already exists in the Vault library:
      1. Select the document.
      2. Select Close.
    • If you’re uploading a new document:
      1. Select Create.
      2. Add the document manually.
  5. Set the document type to either of the following options, as apppropriate:
    • Case › Source › Attachment (C.1.6/A.1.8.1-2)
    • Case › Source › Literature (C.4.r/A.2.2)
  6. Open the document, and complete the document fields.

Case Attachment and Literature Document Fields

In the Document panel, complete the Case attachment and literature document fields in the General and Case sections.

General Fields

Field Description
Name

When you save the document, Vault generates a document name using Vault Safety's naming conventions for the associated document type.

Title

(Optional) Enter a descriptive name for the document.

Type

The document type selected during upload, which should be Case.

Subtype

The document subtype selected during upload, which should be Source.

Classification

The classification selected during upload, which should be Attachment or Literature.

Version

The document version number.

Vault populates this field.

Organization

(Required) Select the Organization associated with the Case.

Lifecycle Stage

The Lifecycle Stage the document is in.

Vault populates this field.

Lifecycle State Stage ID

The Lifecycle State Stage ID the document is in.

Vault populates this field.

Case Access Group

The Case Access Group inherited from the associated Case. Vault populates this field.

This field does not appear on layouts by default. Depending on your organization's security configuration, it may be added by your Admin.

Tags

Vault populates this field with any applicable document tags.

Case Fields

The following document fields appear in either or both of the Attachment and Literature document types.

Field Description
Case

Reference link to the Case.

Vault populates this field when you add the document to a Case.

Inbox Item

Reference link to the source Inbox Item.

Vault populates this field when you create an Inbox Item from a document.

Inbound Transmission

Reference link to an Inbound Transmission.

Vault populates this field if this document was received from an Inbound Transmission.

Retransmit

To include the document in E2B transmissions, select Yes.

For EMA E2B submissions, attachment file size cannot exceed 15 MB. All Vault Safety E2B Transmissions have a maximum total size limit of 100 MB.

For more information, see E2B Document Attachments and Literature References.

Description

For attachments, enter a description of the document. The character limit for this field is 1,500, including spaces.

Description(continue)

For attachments, if the description exceeded the character limit in the Description field, continue the description.

Literature Classification

For literature, select the classification. By default, the following options are available:

  • Clinical trial/research
  • Non-clinical trial/research

Publication Country

For literature, select the country in which the literature was published.

Reference

For literature, enter the citation for the literature reference.

Reference (reason omitted)

For literature, if the citation is unavailable, select the reason why this information is omitted.

Blind Protection

Indicates whether blind protection is enabled for the document.

If the document contains sensitive unblinded data, select On to enable blind protection on the document.

If you enable this option, only authorized users can view the document. By default, only users assigned the Head of Safety or Medical Reviewer user role will be able to view documents with blind protection enabled.

Admins can edit Dynamic Access Control (DAC) sharing rules on the document lifecycle to change which user groups have access to blind-protected documents. See About Dynamic Access Control for Documents for more information on modifying DAC.

Product

To link this document to a Product, select the associated Product record. The options are filtered by the Organization on the document.

Study

To link this document to a Product, select the associated Study record. The options are filtered by the Organization on the document.

Attachment Type

For attachments, identifies if the document is an over-the-counter (OTC) carton image.

When sending FDA E2B(R2) or FDA E2B(R3) Transmissions for a Case with OTC Drugs through an AS2 Connection, select FDA Carton Attachment.

Remove a Document from a Case

  1. On the Case, expand Documents.
  2. Select the link to open the document you want to remove.
  3. Remove the document using either of the following methods:
    • To keep the document in the library but remove it from the Case:
      1. On the document, select Edit Fields.
      2. In the Case field, remove the linked Case by selecting the X icon.
      3. Select Save.
    • To delete the document from the library:
      1. On the document, from the All Actions menu, select Delete.
        This action deletes the document from your library. Once complete, you are redirected to the Library tab.