How should an Oman clinic organise its evidence for DGPHE?

Organise the evidence around the patient record and the self assessment, so every entry is dated, attributed and traceable, and any file can be copied the moment a team asks. DGPHE's 2025 guideline says an electronic record must trace every change to the person who made it and the time.

What the record must show

The Medical Record Documentation Guideline of March 2025 asks for entries that are dated and legible, with the author identified by name and designation and authenticated by stamp, signature, initials or a computer entry that can be validated. Verbal orders are authenticated within 24 hours, and a closed record review runs monthly on a sample of every practitioner's records.¹ DGPHE teams may collect a copy of any file, paper or electronic, during a visit.²

The statistics DGPHE asks for

Every licensed establishment sends DGPHE and its governorate statistics department data at least every quarter, including attendances by ICD-10 diagnosis, nationality, gender and age group, and its registered staff. Diagnoses are classified in ICD-10.³

1. One record per patient. A unique identifier, with multiple records cross-referenced.
2. Authenticate every entry. The author's name, designation and signature or validated login, with the date and time.
3. Review closed records monthly. A sample from every practitioner, with the findings written down.
4. File the self assessment with its evidence. Each item linked to the record or report that proves it.
5. Prepare the quarterly return. Attendances by ICD-10, nationality, gender and age group.

1. Requirement ______
2. Evidence ______ Where it is kept ______
3. Owner ______ Last checked ______
4. Gap found ______ Closed on ______

Copy template

Questions

Are electronic records accepted?

Yes. The guideline allows written, electronic or combined records, and asks electronic records to trace every change.

How often should we review records?

The guideline sets a monthly closed record review on a sample of all practitioners.

What do inspectors do with a file?

They may take a copy of it, paper or electronic, from the medical records department.

Sources

1. 1Ministry of Health, Oman, 2025Medical Record Documentation Guideline, MOH/DGPHE/GUD/016/Vers.02, March 2025Read source
2. 2Ministry of Health, Oman, 2025Supervision and Control Policy for Private Health Establishments, MOH/DGPHE/P&P/006/Vers.01, February 2025 (Arabic)Read source
3. 3Ministry of Health, Oman, 2024Licensing Regulations for Private Health Establishments Manual, MoH/DGPHE/F/013/Vers.003, August 2024Read source

Written by the wai team from Oman Ministry of Health guidance, checked on 16 October 2026. This is guidance, not legal advice. Oman MOH does not endorse wai or any software.