Last updated on Thursday, 15, October, 2026
Table of Contents
Corrective and Preventive Action in Hospitals: What PHC Indicator 162 Requires
A hospital meets PHC Indicator 162 when the result of its medical record review, and any corrective and preventive action taken as a result, is written down. A review that finds problems but leaves no record of what was done about them does not meet the indicator.
This guide explains what to document, how corrective and preventive action differ, where hospitals usually slip, and gives you an action log your quality team can start using this week.
| Regulator | Punjab Healthcare Commission (PHC) |
| Standard | 30 (IMS-3): the organization regularly reviews medical records |
| Indicator | 162 |
| Priority | Critical |
| Applies to | Hospitals that review their medical records |
Indicator 162 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 162 Requires
The indicator says appropriate corrective and preventive measures undertaken are documented. The PHC’s compliance requirement is short: the result of the review process, and the corrective action taken where indicated, must be documented.
Two points follow from the wording:
- The result is always documented, even when the review finds nothing wrong. It is your proof that the review happened.
- Action is documented where indicated. Not every finding needs action, but when one does, what you did about it must be on record.
Why It Is a Critical Indicator
Indicator 162 is the last of four critical indicators in Standard 30, after timeliness, legibility and completeness (159), open and closed records (160) and error correction (161). It closes the loop. Without it, a hospital can review records forever and never improve them. With it, every review leaves evidence of what was found, what was done and who did it.
Corrective vs Preventive Action
- Corrective action fixes the problem that was found, for example completing a missing entry through the proper correction route.
- Preventive action stops it happening again, for example changing a form or training staff.
The PHC deck names both in the indicator. A log that only lists corrective fixes misses half of it.
What to Document After Every Review
The PHC asks for the review result and the action taken. The table below breaks that into six entries your quality team can keep. The “what to write” column is practical guidance.
| # | Entry | What to write | Example |
| 1 | Review result | Date, records reviewed, what was found, and which indicator it relates to | 15 Oct: 20 discharged records reviewed; 6 had no follow-up instructions (Indicator 152) |
| 2 | Is action indicated? | Yes or no, with the reason | Yes: 30% of sampled summaries incomplete |
| 3 | Corrective action | What was done to fix the problem found | Missing follow-up instructions added through dated correction entries (Indicator 161) |
| 4 | Preventive action | What changes to stop it recurring | Follow-up instructions made a required field on the discharge form; ward doctors briefed |
| 5 | Owner and due date | A named person and a date | Ward manager; 31 Oct |
| 6 | Follow-up check | When and how you will confirm the action worked | Re-check 20 discharge summaries in the November review |
The example is illustrative only. Use your own findings.
Fix records through the proper route. A corrective action on a record must follow the PHC correction rule: a separate line with date, time, title and signature, never a cross-out or a backdated entry (Indicator 161).
A clean review is still a result. If a review finds nothing wrong, record that. It is evidence that you looked, covering both open and closed records (Indicators 159 and 160).
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Where Hospitals Usually Fail on Corrective Action
These are the gaps to look for in your own quality files. Each maps to the indicator’s wording.
- Findings with no recorded action. The review noted a problem and nothing shows what was done.
- Action recorded only in meeting minutes, with no link back to the review that triggered it.
- No owner or due date, so the action belongs to everyone and no one.
- Corrective action only. The record was fixed but nothing changed to stop it happening again.
- The same finding every month. If the problem keeps coming back, the preventive action did not work or never happened.
- No follow-up check. No one confirmed that the action worked.
- Clean reviews not recorded, so there is no proof the review took place.
- Fixes made by backdating or overwriting records instead of using the proper correction route (Indicator 161).
If your quality files show more than a few of these, start with a simple action log and make it part of every review.
How to Comply with Indicator 162 in Six Steps
- Keep one action log for all record review findings, in a single place everyone on the quality team can find.
- Record the result of every review, including the date, the records reviewed and what you found (Indicators 159 and 160).
- Decide whether action is indicated for each finding, and write down the reason either way.
- Write both kinds of action. Add a corrective action for the problem found and a preventive action to stop it recurring.
- Give every action an owner and a due date.
- Check at the next review whether the action worked. If the same finding returns, record a stronger action.
Corrective and Preventive Action Log
Print it or copy it into your own system. Add rows as needed.
| ID | Review date | Finding (indicator) | Records affected | Corrective action | Preventive action | Owner | Due date | Status | Checked at next review (date, result) |
At the foot of the log: reviewed by (name and title), signature, date.
How Hospital Software Helps with Action Tracking
An action log in a notebook or a spreadsheet tends to drift away from the records it is about. A hospital management system can keep the two together.
With CoreMedix hospital management software and the Electronic Medical Record from InstaCare:
- Review findings and follow-up actions can be logged alongside the records they concern.
- Each action can carry an owner and a due date, so nothing is left unassigned.
- Corrections are added as dated, signed entries, which supports the PHC correction rule (Indicator 161).
- The next review can pull the same kind of records again, so you can check whether the action worked.
- Review results and actions are in one place when an inspector asks for evidence.
Want to see how it works on your own review process? 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 supports your review, corrective action and the rest of the medical record.
Frequently Asked Questions
What Does PHC Indicator 162 Require?
Appropriate corrective and preventive measures must be documented. The result of the review process and the corrective action taken, where indicated, must be written down.
Is Indicator 162 Critical?
Yes. The PHC marks it as a critical indicator under Standard 30 (IMS-3).
What Is the Difference Between Corrective and Preventive Action?
Corrective action fixes the problem that was found. Preventive action changes something so the problem does not happen again.
Do We Have to Document a Review That Finds No Problems?
Yes. The result of the review must be documented. Record the date, the records reviewed and the finding that no action was needed.
How Do We Fix a Record Error as Part of Corrective Action?
Use the PHC correction rule: a separate line with date, time, title and signature, with no cross-outs, erased entries or fluids (Indicator 161).
How Do We Show an Inspector That Our Actions Worked?
Keep an action log with owners and due dates, and record at the next review whether the finding returned. A finding that disappears is your evidence.
