Last updated on Friday, 23, October, 2026
A hospital faces a recordkeeping review in two ways under the Punjab Healthcare Commission (PHC) MSDS: the hospital’s own regular review of its medical records, which the MSDS requires, and the PHC’s assessment of the hospital during licensing and inspection. Staff meet both in the same way. Every entry is complete, legible, dated and timed, made only by authorized people, and kept private, and mistakes are corrected properly.
This guide is about people, not paperwork. It shows who is responsible for what, what every staff member needs to know about access and accurate entries, how a review works, and a four-week plan to prepare. No plan can promise a result in a PHC review. What it can do is make your staff’s daily habits match what the standards ask for.
| Framework | PHC Minimum Service Delivery Standards (MSDS) for hospitals |
| Area | Information Management Systems (IMS) |
| Review standard | Standard 30 (IMS-3): the organization regularly carries out review of medical records, Indicators 156 to 162 |
| PHC assessment | Pre-assessment and formal inspection during licensing, inspection at renewal, and inspection after a complaint |
For the indicator-by-indicator rules, see our guides to PHC MSDS information management standards and PHC MSDS medical record requirements.
Table of Contents
Who is responsible for what
The MSDS sets what the record must show. It does not assign every task to a job title, so the hospital has to. The table links each responsibility to the indicator behind it. The PHC itself names registration and reception staff, OPD doctors, pharmacists and nurses as staff who date and time entries (Indicator 146). The rest of the role split is good practice, so adapt it to your hospital.
| Who | What they are responsible for | Indicators |
|---|---|---|
| Hospital management and quality team | Keep the written list of people authorized to make entries; set the record review policy; name the reviewers; make sure corrective action is documented | 145, 156, 158, 162 |
| Medical records department | One unique identifier per patient; records stored in good order; hospital deaths documented in the department | 144, 148, 153 |
| Doctors and consultants | Reason for admission, presumptive diagnosis and plan of care; operative notes; a signed discharge note; sign every entry personally | 147, 149, 150, 152 |
| Nurses | Date and time every entry; keep the record current through each shift | 146, 148 |
| Registration and reception staff | Positively identify the patient and the right record; date and time their entries | 144, 146 |
| Pharmacists | Date and time their entries | 146 |
| Record reviewers | Check timeliness, legibility and completeness; cover both open and discharged records; keep access and confidentiality SOPs | 158, 159, 160 |
| Every staff member | Make no entry unless authorized; do not delegate entries; correct errors on a separate dated, timed and signed line | 145, 147, 161 |
The indicators in this table are taken from the PHC’s published hospital standards for Information Management Systems. The PHC marks these indicators as critical: 145, 148, 149 to 154 and 159 to 162, so start your training with those.
Access control: what every staff member needs to know
Indicator 155 asks for two things together. Care providers must be able to see a patient’s current and past records, and the record must be accessible only to authorized, concerned persons, with confidentiality ensured. Indicator 145 adds that only authorized people may make entries, and Indicator 158 asks the review SOPs to say who has access, what information they can access and what confidentiality means.
Staff need those principles turned into plain rules. These are good practice, not PHC wording:
| Rule for staff | Why it matters |
|---|---|
| Open a record only if you are treating that patient or are authorized to review it | Keeps access limited to authorized, concerned persons |
| Never share your login or sign in for someone else | Every entry and every view must trace to one person |
| Lock your screen and sign out when you leave a workstation | Stops casual access by anyone passing |
| Do not leave files on desks, trolleys or counters; return them to the record room | Protects paper records |
| Do not photograph records or forward them on personal messaging apps | Keeps records under the hospital’s control |
| Release copies only through the person your policy names | Prevents ad hoc disclosure |
| Report a lost file or a suspected breach at once | Lets the hospital act and document it |
| Sign a confidentiality undertaking, and renew it when your role changes | Puts the duty in writing |
Strict privacy must not get in the way of care. A treating doctor still has to reach a patient’s history quickly, so test both directions. For the full access matrix and checklist, see our guide to PHC MSDS rules for patient record access and confidentiality.
Accurate records: six habits for every entry
Reviewers read what staff wrote, so the habits behind each entry matter most. These six follow the indicators directly.
- Write both date and time on every entry (Indicator 146).
- Sign with your name and title, so the author can be identified (Indicator 147).
- Never delegate your entry. Authorized persons do not have someone else write for them (Indicator 147).
- Write legibly and completely. The record must be complete and legible, with the reason for admission, the presumptive diagnosis and the plan and progress of care (Indicator 149), and a chronological, up-to-date account of care (Indicator 148).
- Correct an error on a separate line that carries the date, time, title and signature of the person correcting it. Cross-outs, erased entries and correction fluid are not allowed (Indicator 161).
- Record what happens at the key moments: procedures, transfers, discharge and death (Indicators 150 to 154).
For the exact contents of each of those records, see our guides to correcting errors in medical records and PHC MSDS medical record requirements.
