Last updated on Thursday, 15, October, 2026

PHC Information Management Standards (IMS 28-30): A Hospital Guide

The Punjab Healthcare Commission (PHC) judges a hospital’s medical records through three Information Management Systems (IMS) standards: Standard 28 (IMS-1), Standard 29 (IMS-2) and Standard 30 (IMS-3). Together they hold 19 indicators, numbered 144 to 162. Twelve are marked critical and seven non-critical.

In plain terms, the three standards ask three questions about every patient file:

1. Is a complete and accurate record created? (IMS-1, indicators 144-148)
2. Does the record show continuity of care from admission to discharge, transfer or death? (IMS-2, indicators 149-155)
3. Does the hospital regularly review its own records and fix what it finds? (IMS-3, indicators 156-162)

The medical record has three jobs under these standards: to ensure quality of care, to give documentary evidence of the patient’s course of illness and treatment, and to preserve the truth and make review possible. This guide walks through all 19 indicators, shows which ones are critical, and links to a detailed article on each.

Where IMS fits in the 10 MSDS functional areas

IMS is one of ten functional areas in the PHC Minimum Service Delivery Standards (MSDS): Access, Assessment and Continuity of Care (AAC); Care of Patients (COP); Management of Medication (MOM); Patient Rights and Education (PRE); Hospital Infection Control (HIC); Continuous Quality Improvement (CQI); Responsibilities of Management (ROM); Facility Management and Safety (FMS); Human Resource Management (HRM); and Information Management System (IMS).

This guide covers the last one in depth. For the whole framework, read our overview of the PHC Minimum Service Delivery Standards and its ten functional areas.

Critical vs non-critical indicators at a glance

12 of the 19 indicators are critical. Most of them are about what a record must contain (indicators 149-154) and about the review loop (159-162). The non-critical ones are mostly the basics: ID, timestamps, named authors and access.

Standard	Indicators	Critical	Non-critical
28 IMS-1: complete and accurate record	144-148	145, 148	144, 146, 147
29 IMS-2: continuity of care	149-155	149, 150, 151, 152, 153, 154	155
30 IMS-3: regular review of records	156-162	159, 160, 161, 162	156, 157, 158
Total	19	12	7

A hospital can have well-organized files and still miss a critical indicator, for example a discharge note without a qualified signature or a review with no documented corrective action. Treat the critical indicators first.

Standard 28 (IMS-1): a complete and accurate medical record for every patient

IMS-1 is about how a record is created and who is accountable for it. Only 145 and 148 are critical.

Ind.	Priority	What the PHC requires	What the hospital needs in place
144	Non-critical	Every medical record has a unique identifier	A clear mechanism that positively identifies each patient’s record
145	Critical	Policy identifies who may make entries	A written list of authorized people, and checks that only they make entries
146	Non-critical	Every entry is dated and timed	Date and time on each entry by registration staff, OPD doctors, pharmacists, nurses and other authorized staff
147	Non-critical	The author of the entry can be identified	Name and title on every entry; no delegation by authorized persons
148	Critical	An up-to-date, chronological account of care	Records stored in good order and kept for the statute-of-limitations period, with identification, clinical records, and information supporting diagnosis, care, treatment and results

Read more: unique patient identifiers (144); who can make entries, timestamps and author identification (145-147); chronological records, storage and retention (148).

Standard 29 (IMS-2): the record reflects continuity of care

IMS-2 has the most critical indicators: six of its seven. It checks that the record tells the full story from admission to discharge, transfer or death.

Ind.	Priority	What the PHC requires	What the record must contain
149	Critical	Admission reason, diagnosis and plan of care	Complete, legible entries: reason for admission, presumptive diagnosis, documented plan and progress of care
150	Critical	Operative and other procedures	Provider names, procedure undertaken, findings, estimated blood loss, specimens removed, complications, and the patient’s condition at the end
151	Critical	Transfer to another hospital	Date of transfer, reason (on request or otherwise) and name of the receiving hospital
152	Critical	Signed discharge note	A copy of the discharge slip signed by qualified personnel, with identification, admission reason, significant investigation results, procedures, response to treatment, discharge medicines and follow-up instructions
153	Critical	Death certificate	Cause, date and time of death, signed and stamped by the Registrar; all hospital deaths documented in the MR department
154	Critical	Autopsy report	The final report in the record whenever a clinical autopsy is carried out
155	Non-critical	Access to current and past records	Records accessible only to authorized, concerned persons, with confidentiality ensured

Read more: admission and plan of care (149); operative notes (150); transfers (151); discharge summaries (152); death and autopsy records (153-154); access and confidentiality (155).

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Standard 30 (IMS-3): the organization reviews its medical records regularly

IMS-3 turns records into a quality loop: review, find deficiencies, fix them, and prove it. The four critical indicators (159-162) are the ones that show the loop is real.

Ind.	Priority	What the PHC requires	What the hospital needs in place
156	Non-critical	Periodic review of records	A written review policy that defines how often reviews happen and assesses content, completeness and quality
157	Non-critical	A representative sample	Evidence of a sample covering the hospital’s services and staff; generally 10% of records in small hospitals and 5% in large ones
158	Non-critical	Review by identified professionals	Documented evidence that reviewers come from disciplines authorized to make entries; SOPs showing who has access, what they can see and confidentiality
159	Critical	Focus on timeliness, legibility and completeness	Review documentation that shows all three were checked
160	Critical	Open and closed records	Both current patients and discharged patients reviewed: on admission, during stay and on discharge
161	Critical	Deficiencies identified and documented	A process that finds errors; corrections on a separate line with date, time, title and signature; no cross-outs, erasures or correction fluid
162	Critical	Corrective and preventive measures documented	Review results and the corrective action taken, written down

Read more: review policy, sampling and reviewers (156-158); auditing for timeliness, legibility and completeness (159-160); correcting errors (161); corrective and preventive action (162).

Where hospitals slip, and how to prepare

Most gaps come from the critical indicators, because they ask for specific content or proof:

• A discharge note with no signature from qualified personnel, or missing follow-up instructions (152)
• An operative note that leaves out estimated blood loss, specimens or complications (150)
• A transfer with no recorded reason or receiving hospital (151)
• A death record without the Registrar’s signature and stamp, or without cause, date and time (153)
• Errors fixed by cross-outs or correction fluid instead of a signed, dated correction (161)
• A review that was done but never led to a documented corrective action (162)
• Reviews that cover only discharged files, not current patients (160)

Six steps to prepare:

1. Write the list of staff authorized to make entries, by role (145)
2. Check that discharge, operative, transfer and death records have every required field (149-154)
3. Set a written review policy with a frequency, a sample size and named reviewers (156-158)
4. Review a sample of both open and discharged records for timeliness, legibility and completeness (159-160)
5. Correct errors the PHC way and record every deficiency found (161)
6. Document the corrective action taken and who owns it (162)

Prepare with InstaCare

CoreMedix by InstaCare helps hospital teams keep records complete, dated, attributed and ready for review.

• Download the PHC IMS checklist: all 19 indicators, color-coded critical and non-critical.
• Request a demo to see how Hospital Management Software and the Electronic Medical Record handle each indicator.

Frequently asked questions

How many indicators are in the PHC IMS standards?

Nineteen, numbered 144 to 162, across Standard 28 (IMS-1), Standard 29 (IMS-2) and Standard 30 (IMS-3).

Which indicators are critical?

Twelve: 145, 148, 149, 150, 151, 152, 153, 154, 159, 160, 161 and 162.

How many records must a hospital review?

The review uses a representative sample covering the hospital’s services and staff, generally 10% of records in small hospitals and 5% in large hospitals.

How should an error in a medical record be corrected?

On a separate line with date, time, title and signature. Cross-outs, erased entries and correction fluid are not allowed.

Who may make entries in a medical record?

Only the individuals on the hospital’s written list of authorized people. Every entry must show the author’s name and title, and authorized persons may not delegate.

Does the review include discharged patients?

Yes. It covers both open (current) and closed (discharged) records: on admission, during the stay and on discharge.