Last updated on Thursday, 15, October, 2026

Admission Note and Plan of Care: What PHC Indicator 149 Requires

A hospital admission record meets PHC Indicator 149 when every patient’s medical record is complete and legible and contains three things: the reason for admission, the presumptive diagnosis, and a documented plan and progress of care.

This guide explains what to write for each, shows where hospitals usually slip, and gives you a template your wards can start using this week.

Regulator	Punjab Healthcare Commission (PHC)
Standard	29 (IMS-2): the medical record reflects continuity of care
Indicator	149
Priority	Critical
Applies to	Hospitals admitting patients

Indicator 149 is part of the PHC Information Management Systems standards. For all 19 indicators, see our guide to PHC Information Management Standards (IMS 28-30).

What PHC Indicator 149 Requires

The indicator says the medical record contains information about the reasons for admission, the diagnosis and the plan of care. A reviewer checking a patient’s file looks for four things:

1. The reason for admission is written down.
2. A presumptive diagnosis is recorded. This is the working diagnosis the team holds while tests and treatment continue.
3. The plan of care is documented, and so is its progress as the stay goes on.
4. The whole record is complete and legible. A note nobody can read does not count.

Why It Is a Critical Indicator

Indicator 149 is one of six critical indicators in Standard 29, alongside operative procedures (150), transfers (151), discharge (152), death (153) and autopsy (154). The admission note is where the patient’s story begins. Every later entry, from the progress notes to the discharge summary, builds on it, so a gap here carries through the whole file.

What the Record Must Contain

The PHC lists three contents and asks that the record be complete and legible. The “what to write” column is practical guidance for ward teams; the headings are the PHC’s.

#	PHC requirement	What to write	Example entry
1	Reason for admission	The presenting problem in plain words, with when it started and why the patient needs to be in hospital	Fever for 3 days with breathlessness; unable to manage at home
2	Presumptive diagnosis	The working diagnosis at admission. It may change, and the change should be written down	Presumptive diagnosis: community-acquired pneumonia
3	Plan of care	Planned investigations, treatment, monitoring and who is responsible	Chest X-ray and blood tests today; IV antibiotics; review by consultant in the morning
4	Progress of care	Dated and timed progress notes showing how the patient is responding and any change to the plan	Day 2: fever settling, oxygen reduced; continue antibiotics, repeat bloods tomorrow

The examples are illustrative only. Use your own clinical content.

Keep the plan alive. A plan written on admission and never updated is a common problem. When the diagnosis or treatment changes, record the change and the reason in a new, dated entry.

Make it legible. The PHC asks for complete and legible records, so handwriting that nobody else can read is a finding in itself. Legibility is also checked in the record review under Indicator 159.

Many hospitals add more. Medical history, examination findings, allergies, current medicines and consent are common additions to an admission note. They are good practice but not among the three the PHC lists, so add them on top, never instead.

Where Hospitals Usually Fail on Admission Records

These are the gaps to look for in your own files. Each maps to the indicator’s wording.

• Reason for admission missing or vague, for example “for evaluation” with no problem described.
• No presumptive diagnosis on the admission note, so it only appears later in the file, if at all.
• No documented plan of care, only a list of orders.
• No progress notes for days at a time, so the file does not show how care progressed.
• A plan that never changes, even though the treatment did.
• Entries with no name, title, date or time. Every entry should show who wrote it and when (Indicators 146 and 147).
• Illegible handwriting, which fails the “complete and legible” requirement and a legibility review (Indicator 159).
• Admission note and discharge summary that do not match, for example a different diagnosis with no explanation. See our guide to the discharge summary (Indicator 152).

If your wards show more than a few of these, a monthly sample audit will show how widespread the problem is. 

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How to Comply with Indicator 149 in Six Steps

1. Use one standard admission form built around reason for admission, presumptive diagnosis and plan of care, so no ward invents its own format.
2. Set a time limit in your policy for completing the admission note after the patient arrives, and make it known to every admitting doctor.
3. Set a rule for progress notes. Your policy should say how often a patient’s progress is documented, and by whom.
4. Update the plan when anything changes. Record the new diagnosis or treatment and the reason, in a new dated entry.
5. Sign every entry properly with name, title, date and time, and add the signers to your written list of authorized individuals (Indicator 145).
6. Audit a sample every month. Check current and discharged records for the three contents and for legibility, and document what you find and fix (Indicators 156 to 162).

Admission Note Template

Use this as a starting point and adapt the wording to your wards.

Section	Entry
Patient (name, age, sex, MRN, ward, consultant)
Date and time of admission
1. Reason for admission
2. Presumptive diagnosis
3. Plan of care (investigations, treatment, monitoring, responsible doctor)
Written by (name and title)
Signature, date and time

Progress Note (Repeat as Needed)

Section	Entry
Date and time
Progress since last note
Change to diagnosis or plan, and why
Written by (name and title), signature

How Hospital Software Helps with Admission and Progress Records

Paper admission notes are easy to leave thin, hard to read and hard to find. Progress notes scatter across loose sheets. An electronic medical record fixes both.

With CoreMedix hospital management software and the Electronic Health Record from InstaCare:

• Admission notes are typed, so every entry is legible.
• The form carries the three required headings, so reason for admission, presumptive diagnosis and plan of care are not skipped.
• Every entry carries the author’s name, title, date and time automatically.
• Progress notes line up in order in the patient’s record, so anyone can follow the stay from admission onward.
• Your quality team can pull current and discharged records for a monthly audit instead of searching paper files.

Want to see it working on your own wards? Request a demo.

Prepare Your Hospital for PHC Review

• Download the PHC IMS checklist: all 19 indicators, color-coded critical and non-critical.
• Request a demo to see how CoreMedix handles admission notes, progress notes and the rest of the medical record.

Frequently Asked Questions

What Does PHC Indicator 149 Require?

The medical record must contain the reason for admission, the presumptive diagnosis and a documented plan and progress of care, and it must be complete and legible.

Is Indicator 149 Critical?

Yes. The PHC marks it as a critical indicator under Standard 29 (IMS-2).

What Is a Presumptive Diagnosis?

The working diagnosis the team holds at admission while tests and treatment continue. If it changes, record the new diagnosis and the reason.

What Does “Plan and Progress of Care” Mean?

The plan sets out the investigations, treatment and monitoring the team intends. Progress notes show how the patient is responding and record any change to that plan.

Do Progress Notes Need a Date and Time?

Yes. Every entry should be dated and timed and show the author’s name and title (Indicators 146 and 147).

How Can We Check That Our Admission Records Comply?

Review a sample of current and discharged records each month. Check for the reason for admission, a presumptive diagnosis, a documented plan and progress, and legibility. Record the gaps and the corrective action taken.