Last updated on Thursday, 15, October, 2026
Table of Contents
Medical Record Audit Checklist: What PHC Indicators 159 and 160 Require
A medical record audit meets PHC Indicators 159 and 160 when the review checks the timeliness, legibility and completeness of records, covers both open (current) and closed (discharged) records, and leaves documented evidence that it did so.
This guide shows what to check, how to cover patients on admission, during their stay and on discharge, where hospitals usually slip, and gives you an audit sheet your quality team can start using this week.
| Regulator | Punjab Healthcare Commission (PHC) |
| Standard | 30 (IMS-3): the organization regularly reviews medical records |
| Indicators | 159 and 160 |
| Priority | Critical (both) |
| Applies to | Hospitals reviewing their own medical records |
These indicators are 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 Indicators 159 and 160 Require
Indicator 159: the review focuses on timeliness, legibility and completeness. The documentation of the review must show evidence that all three were checked. It is not enough to say a review took place.
Indicator 160: the review includes active and discharged patients. Both “open” records (current patients) and “closed” records (discharged patients) must be reviewed, and the review should reach records on admission, during the stay and on discharge.
Why They Are Critical Indicators
Indicators 159 and 160 are two of the four critical indicators in Standard 30, alongside error correction (161) and corrective and preventive action (162). They are what make a review real: it looks at the right things, in the right records, and leaves proof. A hospital that only reviews discharged files, or only counts whether forms exist, misses the point of the standard.
The three non-critical indicators in the same standard shape how you run the review: a written policy with a stated frequency (156), a representative sample (157), and reviewers drawn from the professionals who are authorized to make entries (158).
What to Check: The Three Tests
The PHC names the three tests. The “what to look for” column is practical guidance for your reviewers.
| Test | What to look for | Example question for the reviewer |
| Timeliness | Entries made at the time of care or within the time your policy sets, with a date and time on each | Was the admission note written within the time limit in our policy? |
| Legibility | A different clinician can read every entry, including names, doses and signatures | Could the next doctor read this without asking the author? |
| Completeness | Every item the PHC expects for that stage is present | Does the discharge file hold a signed summary with all seven contents? |
The PHC does not set a time limit for timeliness in these indicators, so your hospital policy must define one.
What “Complete” Means at Each Stage
Use the PHC’s own record indicators as your completeness list:
- Admission (Indicator 149): reason for admission, presumptive diagnosis, plan and progress of care
- Procedures (Indicator 150): the seven operative note items
- Transfers (Indicator 151): date, reason and receiving hospital
- Discharge (Indicator 152): a signed discharge note with its seven contents
- Death (Indicators 153 and 154): death certificate, and autopsy report where one was done
- Every entry (Indicators 146 and 147): date, time, and the author’s name and title
Open and Closed Records, at Three Points in the Stay
Indicator 160 asks you to review both current and discharged patients. Cover three points:
| Record set | Stage | What the review looks at |
| Open (current patients) | On admission | Admission note, diagnosis and plan in place |
| Open (current patients) | During stay | Progress notes, procedure notes, entries dated and timed |
| Closed (discharged patients) | On discharge | Signed discharge summary, transfer or death documents, whole file complete |
Open records matter because they can still be fixed while the patient is in hospital. Closed records show how the whole stay was documented.
Where Hospitals Usually Fail on Record Reviews
These are the gaps to look for in your own review process. Each maps to the indicators’ wording.
- No written evidence. The review happened, but nothing shows that timeliness, legibility and completeness were each checked (Indicator 159).
- Only discharged files reviewed. Current patients are skipped, so problems are found too late to fix (Indicator 160).
- Only one stage covered, for example discharge, with nothing checked on admission or during the stay.
- Completeness judged by gut feel, with no list of what should be in the file.
- Timeliness never defined, so no one can say whether an entry was late.
- Legibility ignored because “everyone knows what it says”.
- A sample that is not representative, for example only one ward or only one consultant (Indicator 157).
- Findings that go nowhere. Errors are noticed but not written down or acted on (Indicators 161 and 162).
If your review shows more than a few of these, fix the process first, then the records.
How to Comply with Indicators 159 and 160 in Six Steps
- Write a review policy that sets how often reviews happen (Indicator 156) and defines your timeliness limits.
- Draw a representative sample that covers your services and staff. The PHC guidance is generally 10% of records in small hospitals and 5% in large ones (Indicator 157). Check the PHC manual for where “small” ends and “large” begins. For example, a small hospital with 200 discharges a month would review about 20 discharged records, plus a share of current patients.
- Name the reviewers. They should come from the disciplines authorized to make entries in the record (Indicator 158).
- Review both open and closed records, covering admission, the stay and discharge (Indicator 160).
- Test each record for timeliness, legibility and completeness, and write the result down on an audit sheet (Indicator 159).
- Record every deficiency and the action taken. Correct errors the PHC way (Indicator 161) and document corrective and preventive action (Indicator 162).
Record Audit Sheet
Print one sheet per review, or copy it into your own system. Add as many rows as your sample needs.
| Record (MRN) | Open or closed | Stage | Timely (Y/N) | Legible (Y/N) | Complete (Y/N) | Deficiency found | Reviewer and date |
Summary at the foot of the sheet: records reviewed, number open and closed, number with deficiencies, actions assigned (owner and date), reviewer name and title, signature and date.
How Hospital Software Helps with Record Audits
On paper, a record audit means pulling files from shelves, guessing which ones are current and reading handwriting. With an electronic record, the review starts with the data.
With CoreMedix hospital management software and the Electronic Medical Record from InstaCare:
- Records can be filtered by admitted or discharged status, so open and closed samples are quick to pull.
- Every entry carries a date, time and author, which makes timeliness easy to test.
- Typed entries are legible by default.
- Incomplete records can be spotted by missing required fields instead of by reading every page.
- Review results and follow-up actions can sit alongside the records, so the evidence is ready for an inspection.
Want to see a review run on your own records? 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 record audits and the rest of the medical record.
Frequently Asked Questions
What Do PHC Indicators 159 and 160 Require?
The record review must focus on timeliness, legibility and completeness, with documented evidence, and it must include both open (current) and closed (discharged) records.
Are Indicators 159 and 160 Critical?
Yes. The PHC marks both as critical indicators under Standard 30 (IMS-3).
What Are Open and Closed Records?
Open records belong to patients currently in hospital. Closed records belong to patients who have been discharged. The review should include both.
How Many Records Should We Review?
The review should use a representative sample covering your services and staff. The PHC guidance is generally 10% in small hospitals and 5% in large hospitals.
Who Should Carry Out the Review?
Professionals from the disciplines authorized to make entries in the medical record, with documented evidence of who they are (Indicator 158).
How Do We Prove the Review Took Place?
Keep a completed audit sheet for each review showing the records sampled, the result for timeliness, legibility and completeness, the deficiencies found and the actions taken.
