Last updated on Tuesday, 20, October, 2026
Table of Contents
PHC MSDS Medical Record Requirements for Clinics and Hospitals
Under the Punjab Healthcare Commission (PHC) MSDS, a hospital must give every patient one unique, complete and legible medical record, control who can write in it and who can read it, store it in good order, and review and correct it regularly. These rules sit in the Information Management Systems (IMS) area of the MSDS: 19 indicators, 12 of them critical.
This guide explains the requirements in plain language, shows what applies to clinics and what applies to hospitals, and gives six steps to put them in place.
PHC MSDS Medical Record Requirements at a Glance
| Regulator | Punjab Healthcare Commission (PHC) |
| Framework | Minimum Service Delivery Standards (MSDS) |
| Medical record area | Information Management Systems (IMS), Standards 28, 29 and 30 |
| Indicators | 144 to 162 (19 in all), of which 12 are critical (red) and 7 non-critical (yellow) |
| Applies to | Hospitals: the indicators in this guide. Clinics: see “What applies to clinics” below |
The MSDS has ten functional areas, and medical records are one of them. For the full picture, see our guide to the Punjab Healthcare Commission MSDS and the detailed guide to PHC MSDS information management standards.
What the PHC MSDS Says About Medical Records
The MSDS covers medical records in three standards. Together they ask for a record that is complete, that shows continuity of care, and that the organization reviews regularly.
| Standard | What it requires | Indicators | Critical indicators |
|---|---|---|---|
| 28 (IMS-1) | The organization has a complete and accurate medical record for every patient | 144 to 148 | 145, 148 |
| 29 (IMS-2) | The medical record reflects continuity of care | 149 to 155 | 149, 150, 151, 152, 153, 154 |
| 30 (IMS-3) | The organization regularly carries out review of medical records | 156 to 162 | 159, 160, 161, 162 |
Critical indicators (red) are the ones the PHC marks as critical, so fix them first. All 19 indicators still apply, so use the critical ones to set your order of work, not to skip the rest.
Record Keeping Requirements
The PHC asks for a record that identifies the patient, shows who wrote each entry and when, and tells the story of the patient’s care from admission to discharge. The table lists what the PHC asks for, in plain words.
| What the record needs | What it means in practice | Indicator | Priority |
|---|---|---|---|
| A unique identifier on every record | One record number per patient, with a clear way to match the right patient to the right file | 144 | Non-critical |
| A list of people authorized to make entries | The hospital writes down who may write in the record and makes sure only they do | 145 | Critical |
| Date and time on every entry | Registration staff, OPD doctors, pharmacists, nurses and other authorized staff all date and time what they write | 146 | Non-critical |
| An identifiable author | Each entry carries the author’s name and title, and authorized persons do not delegate | 147 | Non-critical |
| An up-to-date, chronological account of care | Records are complete, stored in good order and kept for the period the statute of limitations requires | 148 | Critical |
| Reason for admission, presumptive diagnosis, plan and progress of care | Complete and legible for every patient | 149 | Critical |
| Operative and other procedure notes | Provider names, procedure, findings, blood loss, specimens, complications, patient’s condition | 150 | Critical |
| Transfer details | Date, reason and receiving hospital | 151 | Critical |
| A signed discharge note | A copy in the record, with at least seven contents | 152 | Critical |
| Death certificate and autopsy report | Cause, date and time of death, signed and stamped by the Registrar; final autopsy report where an autopsy is done | 153, 154 | Critical |
For the detail on each row, see our guides to who can make entries, record retention and storage and the unique patient identifier.
Confidentiality and Access to Patient Records
Indicator 155 asks for two things at once. Care providers must be able to see a patient’s current and past records, and the record must be accessible only to authorized, concerned persons, with confidentiality ensured. Indicator 158 adds that the review SOPs should state who has access, what information they can access, and confidentiality.
The PHC states the principle, not the design. These steps are practical guidance, not PHC requirements, for turning it into a working system:
- Write an access list by role. A treating doctor needs the full clinical record, a pharmacist needs prescriptions, and a billing clerk needs billing data.
- Control the physical record. Keep files in a locked room with a sign-out register, and never leave them on desks or trolleys.
- Control the electronic record. Give each person a named login, set role-based permissions, and keep an access log so you can tell who opened a record.
- Get confidentiality in writing. Staff, reviewers and trainees with access sign a confidentiality undertaking.
- Set a rule for copies. Decide who may release a copy of a record, to whom, and whether photographs or messaging apps are ever allowed.
For the full access matrix and checklist, see our guide to PHC MSDS rules for patient record access and confidentiality.
Reviewing and Correcting Records
Standard 30 (IMS-3) asks hospitals to check their own records on a schedule, fix what they find, and write down what they did.
| Step | What the PHC asks for | Indicator | Priority |
|---|---|---|---|
| Set a review policy | A written policy for the periodic review of records, including how often | 156 | Non-critical |
| Review a fair sample | A representative sample of records | 157 | Non-critical |
| Use identified reviewers | Reviewers from disciplines authorized to make entries, with SOPs on access and confidentiality | 158 | Non-critical |
| Check timeliness, legibility and completeness | The review focuses on these three things | 159 | Critical |
| Cover open and closed records | Both current and discharged files are reviewed | 160 | Critical |
| Correct errors properly | Errors are fixed on a separate dated, timed and signed line, with no cross-outs, erasures or correction fluid | 161 | Critical |
| Record the corrective action | The review results and the corrective and preventive action are written down | 162 | Critical |
The last step is easy to forget: a review that finds problems but leaves no record of what was done about them does not meet Indicator 162. See our guides to the medical record audit checklist, correcting record errors and corrective and preventive action.
What Applies to Clinics and What Applies to Hospitals
The PHC sets minimum service delivery standards for several kinds of provider, including hospitals and small clinics, according to the Government of Punjab. The 19 indicators in this guide come from the PHC’s IMS standards for hospitals. We have not seen a PHC document that lists the same indicators for clinics, so confirm the standard for your category with the PHC before you treat this list as your clinic checklist.
The record rules still matter to outpatient care. The PHC’s own wording on dating and timing entries names registration and reception staff, OPD doctors, pharmacists and nurses. A clinic can follow the same ideas on a smaller scale. This is good practice, not a PHC requirement:
| Area | Hospital (PHC IMS indicators) | Clinic (suggested starting point) |
|---|---|---|
| Identification | Unique identifier on every record (144) | One patient number on every visit and prescription |
| Entries | Written list of authorized authors; date, time, name and title on every entry (145 to 147) | Every note dated, timed and signed by the clinician |
| Care record | Admission, procedure, transfer, discharge and death records (149 to 154) | Visit notes with diagnosis, treatment plan and follow-up |
| Storage and access | Records stored in good order; access limited to authorized persons (148, 155) | Locked cabinet or password-protected system; no open files at reception |
| Review | Written review policy, reviewers, corrective action (156 to 162) | A simple monthly check of a few records, with fixes written down |
How to Put Medical Record Requirements in Place: Six Steps
- Give every patient one record number. Use it on every visit, report and prescription, and check for duplicates at registration.
- Write down who may make entries. List each person or role, and require date, time, name and title on every entry.
- Set the content of each record type. Agree what admission notes, procedure notes, transfer notes, discharge summaries and death records must contain, and build a template for each.
- Control access and storage. Lock paper records, use named logins for electronic ones, and sign a confidentiality undertaking with every person who has access.
- Review on a schedule. Check a sample of open and discharged records for timeliness, legibility and completeness, using a written policy and named reviewers.
- Fix and record. Correct errors on a separate dated, timed and signed line, then write down what you found and what you changed.
Start with the critical indicators: 145, 148, 149 to 154 and 159 to 162.
How InstaCare’s Clinic and Hospital Software Helps
Paper records depend on locked doors, handwriting and good habits. A digital record can build many of the rules into the system and leave a trail.
With InstaCare’s clinic management software or hospital management software, built around the Electronic Medical Record:
- Each patient keeps one unique record number across visits and admissions.
- Each staff member signs in with a named login, so every entry carries an author, a date and a time.
- Role-based permissions limit what each role can see, which mirrors your access list.
- An access trail shows who opened a record and when.
- Structured notes and templates help staff capture the same contents every time.
- Records can be searched and pulled for a review sample without hunting through files.
Want to see how this works in a live record? Request a demo.
Frequently Asked Questions
What Are the Medical Record Requirements Under the PHC MSDS?
The record requirements sit in the Information Management Systems (IMS) area: Standards 28, 29 and 30, covering Indicators 144 to 162. They ask for a unique, complete record for every patient, controlled access and confidentiality, a record that shows continuity of care, and regular review with documented corrective action.
How Many Indicators Are There, and Which Are Critical?
There are 19. Twelve are critical: 145, 148, 149, 150, 151, 152, 153, 154, 159, 160, 161 and 162. The other seven (144, 146, 147, 155, 156, 157 and 158) are non-critical.
Do Clinics Have to Follow the Same Indicators as Hospitals?
The PHC sets standards for both hospitals and small clinics, but the 19 indicators in this guide come from its hospital IMS standards. Check the standard for your category with the PHC. Until then, the same record-keeping ideas are a sound starting point.
Who Is Allowed to See a Patient’s Record?
Only authorized, concerned persons. The PHC does not give a list, so define it by role in a written access list, and make sure care providers can still see current and past records.
How Should a Medical Record Error Be Corrected?
On a separate line that is dated, timed and signed, with no cross-outs, erased entries or correction fluid (Indicator 161).
Do We Need Software to Meet These Requirements?
No. None of the 19 indicators requires software. Software makes some rules easier to keep, such as unique record numbers, named logins and access trails.
Request a Demo to See How InstaCare Handles Medical Records, Access and Confidentiality
