PHC MSDS Internal Audit Preparation: Recordkeeping Checklist for Clinics

Last updated on Friday, 23, October, 2026

A clinic internal audit of records is a short, scheduled check of your own patient files against a written checklist, with the results scored, the problems logged and each fix given an owner and a date. It lets you find gaps before the Punjab Healthcare Commission (PHC) does. The PHC’s licensing process includes a pre-assessment, in which surveyors help staff find and fix gaps, before a formal inspection (PHC licensing process). An internal audit is how you do the same job for yourself, every month.

Two things to know before you start:

• The PHC does not call this an “internal audit” for clinics. We could not find a PHC audit form for clinics. This guide is a method built on the principles in the PHC’s hospital standard for record review (Standard 30): a written policy that sets how often, a representative sample, identified reviewers, a focus on timeliness, legibility and completeness, both open and discharged records, and documented corrective action.
• The checklist items are labelled. Where an item comes from a PHC indicator, we give the number. Everything else is good practice, so check your category’s MSDS for the clinic version.

This guide is about auditing the patient record. For the list of licence, staff and SOP documents a clinic should keep, see our PHC MSDS documentation checklist for clinic administrators. For the rules themselves, see PHC MSDS medical record requirements.

Before you start: scope, auditor, sample and schedule

Decide five things once, write them on one page, and keep that page with your audit sheets. The right column shows where each idea comes from. The suggested numbers are good practice, so adjust them to your clinic’s size.

Decision	Suggested approach	Where it comes from
How often	Monthly, in one short sitting	The PHC hospital standard asks the review policy to say how often (Indicator 156)
Which records	A representative mix: different doctors, different days, new and follow-up visits, and a few older files	Representative sample (Indicator 157); open and discharged records (Indicator 160)
How many	Start with about 10 records a month. Check more if you find many gaps	Our suggestion. The PHC does not set a number for clinics that we could find
Who audits	A named person who did not write the entries being checked, for example the clinic manager or a second clinician	Identified reviewers from the disciplines that make entries (Indicator 158)
What gets kept	The completed audit sheets, the findings log and the actions taken	Documented results and corrective action (Indicator 162)

Tell your team the audit exists, what it checks and that it is meant to fix problems, not to blame people. Staff who expect blame tend to hide gaps.

The recordkeeping audit checklist for clinics

Copy this sheet once for each record you audit. Mark every line Yes, No or N/A. The Basis column shows the PHC hospital indicator the check follows, or marks it as good practice. The PHC’s hospital indicators are the closest guide we have, and a clinic’s own MSDS may word them differently.

#	Area	Check	Basis	Yes / No / N/A
1	Identification	The record has a unique patient number, used on every visit and prescription	Indicator 144
2	Identification	Name, age, sex and contact details are recorded and match registration	Indicator 148 (identification of the patient)
3	Entries	Every entry has both a date and a time	Indicator 146
4	Entries	Every entry shows the author’s name and title	Indicator 147
5	Entries	Only people on the clinic’s authorized list made entries	Indicator 145
6	Entries	No entry was written on behalf of another clinician	Indicator 147
7	Content	Reason for the visit is recorded	Good practice (clinic version of Indicator 149)
8	Content	Diagnosis, or presumptive diagnosis, is recorded	Good practice (clinic version of Indicator 149)
9	Content	Treatment plan and follow-up are recorded	Good practice (clinic version of Indicator 149)
10	Content	Investigations ordered and their results are filed with the record	Indicator 148 (information supporting diagnosis and results of treatment)
11	Content	Any referral records the date, the reason and the receiving facility	Indicator 151, written for transfers
12	Consent	A signed consent form is present where a procedure needs one	Good practice
13	Quality	Entries are legible	Indicator 159
14	Quality	Entries were written at the time of the visit, not weeks later	Indicator 159 (timeliness)
15	Quality	No section is left blank without a reason	Indicator 159 (completeness)
16	Corrections	Any correction is on a separate line with date, time, title and signature, with no cross-outs, erasures or correction fluid	Indicator 161
17	Retrieval	The record was found within a few minutes of asking	Good practice (supports Indicator 155)

Audit current records and records of patients who have finished treatment, as the PHC hospital standard asks (Indicator 160). For the full requirement behind each line, see our guides to correcting errors in medical records and PHC MSDS medical record requirements.

Scoring the audit and logging findings

Scoring is good practice. It only has to be simple and used the same way every month.

1. Score each record. Count the Yes answers, divide by the Yes and No answers together (leave N/A out), and write the percentage.
2. Score each check across the sample. If check 3 (date and time) fails on four of ten records, you have a habit to fix, not four isolated slips.
3. Rate each gap. A suggested scale: High for anything that affects who the patient is, who wrote an entry, what care was given or whether the record can be found (checks 1, 4 to 12, 16 and 17); Medium for gaps in details, timing, legibility or completeness (checks 2, 3 and 13 to 15).
4. Set your own target. For example, no High gaps on any audited record.

Put every gap in a findings log. This is what the PHC hospital standard means by documenting the results and the corrective action (Indicator 162). Here is a template, with one example row:

Date	Record no.	Check	Finding	Rating	Action	Owner	Due	Status
Example: 5 Nov	10482	3	Two visit notes have a date but no time	Medium	Add a time field to the visit note template and brief all clinicians	Clinic manager	12 Nov	Open

At the next audit, first check that last month’s actions were done, then move on to the new sample. For how to word the actions, see our guide to corrective and preventive action in hospitals.

The walk-through: storage, access and confidentiality

A record can be perfectly written and still fail an audit if anyone can pick it up. Do this part as a short walk through the clinic, with the sheet in hand, once the paper or screen checks are done. Basis: Indicator 155 for hospitals (confidentiality of patient information); the steps below are good practice for a clinic.

• Where are the records kept? Paper files should sit in a lockable cabinet or room, not on the reception desk or in a corridor. Electronic records should sit behind a login.
• Who can open them? Ask the clinic lead for the list of staff allowed to see patient records, then compare it with who actually does. Note anyone using a shared login.
• Can you trace a view or a change? For paper, a sign-out register is enough. For software, check that it shows who opened or edited a record and when.
• What happens to a record when a patient asks for a copy? Look for a written step: who approves it, how identity is checked, and where the request is noted.
• What do front-desk staff say when asked about a patient by phone? Ask two people. Consistent answers matter more than a polished policy.

For how access rules are usually built, see our guide to patient record access and confidentiality under the PHC MSDS. Mark what you find on checks 16 and 17 of the sheet and log any gap in the findings table.

Using your results to prepare for a PHC visit

An internal audit is practice, not a pass mark. The Punjab Healthcare Commission (PHC) inspects when it issues or renews a licence, after complaints, and as part of periodic review, and its published licensing process includes a pre-assessment where surveyors help a clinic find and fix gaps. Your audit gives you a head start on that conversation.

1. Close the High gaps first. Fix anything that affects patient identity, authorship of entries, the care given or whether a record can be found.
2. Keep the evidence. File the completed sheets, the findings log and proof of each fix together. If an inspector asks how you check your records, you can show it.
3. Brief the team. Share the common gaps with staff in a short meeting, the same week.
4. Re-audit. Repeat on a fresh sample within the period you set, and compare the scores.
5. Build your inspection-day pack. Our PHC MSDS documentation checklist for clinic administrators lists what to have ready.

PHC inspection reports in the press describe the kinds of problems inspectors find, including poor patient record maintenance, so this is a sensible area to check early. An audit shows where you stand; it does not decide your licence, and only the PHC can do that.

How InstaCare’s Clinic Management Software can support your audits

Paper audits work, but they take time, and the same gaps tend to return. Clinic management software can make several checks easier: mandatory fields that stop incomplete entries, automatic date, time and user stamps, role-based access, and search that finds a record in seconds.

Software helps you keep better records; it does not make a clinic compliant by itself. Compliance depends on your processes, your staff and the PHC’s own assessment. If you want to see how a system handles patient records, audit trails and access control, explore our clinic management system.

Book Free Demo Now!

Frequently asked questions

What is a PHC MSDS internal audit?

It is a check your clinic runs on itself, sampling patient records against a fixed list to find gaps before the Punjab Healthcare Commission does. It is not an official PHC process, and the PHC does not require this particular format.

How many records should we audit?

There is no official number. A common starting point is around ten records per audit, mixing new and returning patients and different staff. Adjust to your clinic’s size.

How often should we run it?

Monthly or quarterly suits most clinics. Choose a rhythm you can keep, and re-audit after fixing any High gap.

Who should carry out the audit?

Someone who does not write most of the records, such as a senior nurse or clinic manager, so the review is fair.

Is the checklist an official PHC document?

No. It is based on the closest published guide, the PHC’s hospital indicators, plus good practice. A clinic’s own MSDS may word things differently, so check it against the PHC’s current clinic standards.

Does passing our own audit mean we will pass a PHC inspection?

No. It helps you prepare, but the PHC decides on licensing after its own assessment.

Ready to make audits easier?

See how InstaCare’s clinic software supports record keeping, access control and audit trails.

Book Free Demo Now!