Last updated on Thursday, 22, October, 2026
A clinic’s paperwork has to show three things to the Punjab Healthcare Commission (PHC): that it is registered and licensed, that qualified, registered staff provide only the services it is registered for, and that it follows the Minimum Service Delivery Standards (MSDS) for its category. This checklist sorts the documents you keep by their legal status, so you know what the law requires, what the standards expect, and what is simply good practice.
Every item below carries one of three labels:
| Label | Meaning |
|---|---|
| Law | Comes from the Punjab Healthcare Commission Act 2010 and is binding |
| Standard | Comes from the PHC MSDS, which the PHC applies through licensing |
| Good practice | Our suggestion. Useful, but not a PHC requirement |
The PHC issues the MSDS and a Reference Manual for each category of healthcare establishment, so check the version for yours before you rely on any list, ours included. For the medical record rules in detail, see our guide to PHC MSDS medical record requirements.
Table of Contents
What is Binding and What is Guidance?
Not every document the PHC asks about has the same force. The table shows where each rule comes from.
| Source | What it is | Status | Why it matters to your paperwork |
|---|---|---|---|
| Punjab Healthcare Commission Act 2010 | The law (Act XVI of 2010) | Law | A provider may not offer healthcare services without registration (section 13) and may use an establishment only under a PHC licence (section 14). A licence is valid for five years (section 16) |
| Same Act, section 22 | Inspections | Law | Inspection teams can visit when a licence is issued or renewed, or after a complaint. Refusing or failing, without reasonable cause, to give them information can bring a fine of up to Rs 50,000 |
| Licensing Regulations 2020 | Detailed registration and licensing rules under the Act | Law | Check the current text on the PHC website for forms, fees and conditions |
| MSDS for your category | Minimum standards notified by the Government (section 2) and implemented by the PHC (section 20) | Standard | According to the PHC, a regular licence requires total compliance with the MSDS. Partial compliance can lead to a conditional licence |
| MSDS Reference Manual | Explanatory guide issued with the MSDS | Standard (guide) | Read it together with the MSDS for your category |
| This checklist’s workflows and templates | Our suggestions | Good practice | Not binding. Adapt them to your clinic |
The penalties are real. The PHC’s licensing FAQ says a provider that does not implement the MSDS on time may be fined up to Rs 500,000 or ordered closed until it meets them. Licences can also be suspended, revoked or refused renewal for failing the standards or refusing inspection. In September 2026 the PHC carried out 1,856 regulatory inspections and sealed four centres (Pakistan Observer).
Checklist 1: Your registration and licence file
Keep one file, on paper and as scans, that shows your clinic is legally entitled to operate. The PHC’s licensing process runs from registration to a provisional licence, MSDS training, a pre-assessment and a formal inspection before the regular licence.
| Document | Label | What to keep |
|---|---|---|
| Registration application on the PHC prescribed form, and the PHC’s acknowledgement | Law (section 13) | The submitted form and proof of submission. The PHC says registration carries no fee |
| Licence application with the prescribed documents and fee | Law (section 15) | The application, the documents attached to it and the fee receipt. The application is due within 30 days of registration unless the Government sets another period |
| Affidavit on stamp paper | Law (prescribed form) | The PHC’s registration form for clinics without indoor facilities lists it as an attachment. Download the current form from the PHC site to see the full list |
| Provisional licence and the MSDS and Reference Manual for your category | Standard | The PHC issues these when it receives your application, with a deadline to implement the standards |
| Regular licence | Law (section 16) | The original, valid five years. Note the expiry date in a diary or reminder system |
| Renewal application and fee receipt | Law | Renewal needs an inspection survey, and the PHC will not issue the renewed licence until it receives the fee |
| MSDS training attendance records | Good practice | The PHC invites staff to MSDS training. Keep proof of who attended and when |
| Pre-assessment or inspection report and your reply | Good practice | Keep each report and the actions you took on it |
Checklist 2: Staff and scope of practice
Two of the problems the PHC reported from its September 2026 inspections were clinics operating beyond the scope of their registration and clinics without qualified, registered doctors (Pakistan Observer). Your staff and scope documents answer both.
| Document | Label | What to keep |
|---|---|---|
| Licence stating the kind and purpose of the establishment | Law (sections 14 and 17) | A clinic may be used only as its licence allows. List the services you offer next to the licence and check that each one is covered |
| Licences from other regulators where they apply | Law (other regulator) | The PHC’s inspectors also flagged missing approvals from the Pakistan Nuclear Regulatory Authority and the Punjab Blood Transfusion Authority. Keep these if you offer imaging or blood services |
| Qualification certificates and council registrations for every doctor and clinical staff member | Good practice | A copy for each person, with the registration number and expiry date |
| Staff list with role, joining date and scope of duties | Good practice | One current list, updated when anyone joins or leaves |
| Signed and dated duty roster | Good practice | Keep past rosters too, so you can show who was on duty on a given day |
| Supervision records for junior staff | Good practice | Who supervised whom, and for which tasks |
The exact staffing documents your clinic needs depend on its category, so confirm them against your MSDS.
Checklist 3: Patient records
The PHC listed poor maintenance of patient records among the problems it found in its September 2026 inspections. The detailed record rules in the PHC’s published hospital standards cover unique patient identifiers, who may make entries, dated and timed entries, confidentiality, correction of errors and regular review. We explain them in our guide to PHC MSDS medical record requirements, including which of them we could not confirm for clinics.
For a clinic, a sensible record file covers these points. They are good practice, so check them against your category’s MSDS:
- One patient number on every visit, prescription and report.
- Every note dated, timed and signed by the clinician, with name and title.
- Errors corrected on a separate, signed and dated line, never by overwriting or using correction fluid.
- Records kept locked or password-protected, with access limited to the staff who need them.
- A written consent form where a procedure calls for one.
- A simple monthly check of a few records, with any fixes written down.
Checklist 4: SOPs and safety logs
The PHC’s September 2026 inspection findings also named gaps in infection prevention and control, sterilisation and disinfection, healthcare-waste disposal and expired medicines, reagents and disposable supplies (Pakistan Observer). Written procedures and dated logs are how you show that you handle each one. The list below is good practice. We could not find a single public PHC list of required SOPs for every clinic, so check your category’s MSDS for what it expects.
| Area | Written procedure | Log or evidence to keep |
|---|---|---|
| Infection prevention and control | Hand hygiene, protective equipment, cleaning schedule | Cleaning logs and staff training records |
| Sterilisation and disinfection | How each instrument is cleaned and sterilised | Sterilisation record for each cycle, with date and initials |
| Healthcare waste | Segregation, storage and disposal of sharps and other waste | Waste handler contract and collection records |
| Medicines and supplies | Storage, stock rotation, expiry checks | Dated expiry-check log, and a record of items removed |
| Equipment | Cleaning, servicing and calibration where it applies | Equipment list and maintenance record |
| Emergency readiness | What staff do in a medical or fire emergency | Drill record and emergency contact list |
| Complaints | How patients can complain, and how you respond | Complaint register with date, action and outcome |
| Consent and patient rights | When consent is needed and how it is recorded | Signed consent forms and a displayed patient rights notice |
Documentation Workflows: who does what, and how often
A document only helps if someone owns it and checks it. This is a good practice routine you can adopt in a small clinic. Name one person for each row.
| Document | Owner | Where it lives | When it is checked | Evidence of the check |
|---|---|---|---|---|
| Licence and registration file | Clinic administrator | Locked file and scanned copy | Every quarter, and 90 days before expiry | Dated note in the file |
| Staff credentials and roster | Clinic administrator | Staff files | When anyone joins or leaves, and every six months | Updated staff list |
| Patient records | Lead clinician | Record cabinet or clinic system | Monthly sample of a few records | Short review note with fixes |
| Infection control and sterilisation logs | Nurse in charge | At the point of use | Weekly | Supervisor’s initials and date |
| Medicine and supply expiry check | Pharmacy or stock lead | Stock register | Monthly | Dated log, removed items recorded |
| Waste collection records | Nurse in charge | Waste log | Each collection | Signed collection slip |
| Complaint register | Clinic administrator | Complaint file | Monthly | Each complaint closed with an outcome |
Keep the monthly checks to one short meeting. Write down what was checked, what was found and who will fix it by when. That note is the evidence that your paperwork is alive and not just filed.
Your PHC inspection checklist for Clinics: The inspection-day pack
The PHC can inspect when a licence is issued or renewed, after a complaint, or during periodic review. Keep this pack in one place so it can be handed over in minutes.
- ☐ Registration acknowledgement and regular licence (original), with expiry date
- ☐ The MSDS and Reference Manual for your category
- ☐ Licences from other regulators, where you offer imaging or blood services
- ☐ Staff list, qualification certificates, council registrations and the current duty roster
- ☐ A sample of recent patient records, complete and legible
- ☐ Consent forms and the complaint register
- ☐ Infection control, sterilisation, waste and expiry-check logs for the last few months
- ☐ Equipment list and maintenance records
- ☐ Notes from your last internal check, with fixes and who made them
One legal point matters on the day. The Act allows a fine of up to Rs 50,000 for refusing or failing, without reasonable cause, to give the inspection team information, and for giving false or misleading information (section 22). Answer plainly, give only what is true and hand over documents you hold. The Act also says inspection teams must not disclose patient record information unless the PHC allows it in writing.
How Clinic Management Software can support your documentation?
Software does not make a clinic compliant. Compliance depends on your licence, your staff and how you work every day. What a digital system can do is keep records in one place, show who changed what, and remind you when something is due.
When you look at any clinic system, check whether it can:
- Give each patient one record number and keep every visit under it.
- Date, time and name the author of every entry.
- Limit who can open which records, and keep an access trail.
- Keep staff and licence details with expiry reminders.
- Hold logs and registers, such as stock expiry checks, in a searchable form.
- Pull a sample of records quickly for your monthly check.
To see how this works in a clinic, explore InstaCare’s Clinic Management software.
Frequently asked questions (Faqs)
What documents does the PHC check during a clinic inspection?
We could not find one public PHC list that applies to every clinic. The PHC’s own reports of recent inspections point to licences and registration, staff qualifications, patient records, infection control, waste disposal and expired supplies. Use the checklists above and confirm the details in the MSDS for your category.
Is the MSDS legally binding?
The Act defines standards as including the minimum service delivery standards notified by the Government, and the PHC implements them (sections 2 and 20). The PHC says a regular licence requires total compliance with them, and failing to implement them on time can bring a fine of up to Rs 500,000 or closure until the standards are met. For legal advice on your clinic, speak to a lawyer.
What is the difference between law, standard and good practice?
Law is the Act and the regulations under it. Standards are the MSDS the PHC applies when it licenses you. Good practice is advice, such as the workflows in this guide, that helps you meet both but is not itself a PHC requirement.
How long is a PHC licence valid?
Five years (section 16). Renewal needs an inspection survey and payment of the licence fee.
Do clinics and hospitals follow the same MSDS?
No. The PHC publishes separate MSDS and reference manuals for categories such as Category I to II-C hospitals, GP and specialist clinics, dental clinics, laboratories, basic health units and imaging centres. Request the one for your category from the PHC.
Does software make a clinic PHC compliant?
No. Software can help you keep records, reminders and logs in order. Compliance depends on your licence, your staff and your daily practice.
