Ministry of Health

Document Title Policy and Procedures of Out on Pass

Document Type Policy and Procedures
Directorate/Institution Directorate General of Specialized Medical Care
Targeted Group all staff involved in patient care and for all health care institutions
operating under the management of Ministry of Health (MoH)
Document Author Dr. Rashid Al Shakaili
Designation HoD, Hospital Affairs
Document Reviewer Dr. Adil Salih Al-Ansari
Mrs. Sharifa Al-Zadjali
Designation Assistant Director – Directorate General of Specialized Medical
Care
Release Date December 2022
Review Frequency 3 years

Validated by Approved by
Name Dr.Qamra AlSariri Name Dr.Said Al Lamki

Designation Designation DG of DGSMC

DG of DGQAC
Signature Signature

Date December2022 Date December 2022

MoH/DGSMC/P&P/024/Vers.01 December 2022 Page 1 of 14

Contents Table:

Acronyms: .....................................................................................................................................3
1. Introduction ........................................................................................................................4
2. Scope ..................................................................................................................................4
3. Purpose...............................................................................................................................4
4. Definitions..........................................................................................................................4
5. Policy .................................................................................................................................4
6. Procedure ...........................................................................................................................6
6.1 Procedures before patient leave………………………………………….……………..7
6.2 Procedures after patient leave………………………………….……………………….7
6.3 Procedures after patient return…………………………………………………………8
6.4 Going home with peripheral IV cannula…………………………………….………….8
7. Patient failure to report back ..............................................................................................9
8. Document History and Version Control ..........................................................................11
9. Related Documents..........................................................................................................11
10. References ........................................................................................................................12
11. Appendix 1: Out on Pass Form…………………………………………………………….13
12. Appendix 2: Algorithm of Steps to Follow when Patient Fails to Return from OOP……..14

MoH/DGSMC/P&P/024/Vers.01 December 2022 Page 2 of 14

Acronyms

OOP Out on Pass

MOH Ministry of Health
PRO Public Relations Officer
A/E Accident & Emergency
OPD Outpatient Department
IV Intravenous
TB Tuberculosis

MoH/DGSMC/P&P/024/Vers.01 December 2022 Page 3 of 14

 Policy and Procedures of Out on Pass
1. Introduction
Patients may sometimes require a short leave from the hospital as a part of their care plan or
due to some exceptional circumstances. It is important to consider issuing such leave instead
of discharging the patient and arranging readmission few days later. However, such leave
should only be given if it is consistent with the best practice and has no negative impact on
patient’s safety or the quality of care delivered. Therefore, in order to enable medical staff
granting patients a temporarily leave without jeopardizing their safety, the following policies
and procedures have been established for facilitation.

2. Scope
These policies and procedures are applicable to all staff involved in patient care and for all
health care institutions operating under the management of Ministry of Health (MoH)

3. Purpose
3.1 To standardize the out on pass policies and procedures.
3.2 To make the process of granting out on pass smoother.
3.3 To maximize the safety of patients going out on pass.
3.4 To make the hospital environment more friendly and responsive to patients'
circumstances.
3.5 To maximize the efficient use of hospital resources.

4. Definitions
4.1 Out on Pass (OOP): a temporary absence from the hospital without being officially
discharged and with intent to return back for further treatment. This does not include the
authorized short absence from the unit/ward for a walk around hospital grounds.
4.2 Therapeutic Pass: a planned and supervised leave from a health care facility ordered
by the patient's treating doctor as a part of the patient management plan.

5. Policy
5.1 This document represents the main reference for out on pass policies and procedures in
MoH. All hospitals' local policies and guidelines have to be modified to conform to the
policies and procedures stated in this document.

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 5.2 Out on pass (OOP) should be granted only under extreme circumstances (e.g. death in
the family, long hospital stay, etc.) and only upon completing patient assessment and
considering all aspects, the condition, and the involved risks.
5.3 The OOP can only be granted by the treating doctor. However, if the patient is also being
treated or followed up by specialties/departments other than the admitting one then the
treating doctor should discuss with them before granting the OOP.
5.4 The OOP cannot be granted to:
5.4.1 Legally unqualified patients (e.g. minors, people with mental disabilities) without
a consent from an authorized person.
5.4.2 Patients exposing risk to the public or themselves (e.g. active TB patients,
severely depressed patients, patients with repeated seizures, etc.)
5.4.3 Patients with impaired consciousness.
5.4.4 Patients under police custody or surveillance (except in situations where they
leave the hospital under police responsibility e.g. for court hearing).
5.5 The treating doctor has the discretion to reject an OOP request for any other significant
reasons.
5.6 A patient who insists to leave the hospital after rejecting his/her OOP request will be
leaving against medical advice, and "leave against medical advice" procedures have to
be followed.
5.7 The OOP permitted period should not exceed 48 hours (starting from the time the patient
physically leaves the unit/ward, not the time of requesting the OOP or signing the form).
5.8 In situations where the patient asks for OOP extension beyond the maximum permitted
period due to any significant reason, the treating doctor has the discretion to accept or
reject the extension based on patient's clinical condition. However, under no
circumstance should the total OOP period exceed 72 hours.
5.9 If the OOP is issued for therapeutic purposes (therapeutic pass), then the permitted OOP
period will be specified by the treating doctor based on patient's management plan.
5.10 If a patient exceeds the allowed OOP period, then he/she is to be discharged and re-
admitted if the treatment is to be continued (according to the rules explained in the
procedures section below).
5.11 The MoH "Out on Pass Form" (Appendix 1) is the only form authorized for use in MoH
hospitals to grant an OOP. However, this form is not applicable to patients going for
therapeutic pass since the OOP is not requested by the patient.

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 5.12 For therapeutic pass, the OOP form can be substituted by a brief report summarizing the
patient’s condition, management plan, indication for the therapeutic pass and its period,
and any other important information.
5.13 The length and reason for OOP have to be clearly specified in the OOP form.
5.14 The OOP form is to be signed by the patient or authorized attendant, the treating doctor,
and the unit/ward nurse in-charge.
5.15 For patients going OOP under the responsibility of police or another legal authority, the
police officer/lawman who takes the patient out has to sign the OOP form and not the
patient (after verification of the legal documents and the police officer identity by the
PRO).
5.16 All information and details related to the patient’s OOP have to be documented in the
patient’s medical record, including the completed OOP form.
5.17 If the patient is on a particular type of treatment, then that treatment has to be continued
throughout the OOP period, and the medical staff should make sure that the patient has
received the required medications/consumables and knows how to use them.
5.18 The OOP medications/consumables should be dispensed to the patient in the ward (from
the patient’s medication drawer) and not in the pharmacy. If the medications are not
enough or available in the medication drawer then they should be requested and
collected from the pharmacy and given to the patient in the ward.
5.19 If the patient has to continue any type of therapy that requires administration by a
medical staff (e.g., intravenous fluids, injections, nebulization, etc.), then the treating
doctor has to provide the patient with a brief report explaining the patient’s condition
and the advised therapy so that the patient presents it to the staff where he/she will
receive the treatment (e.g. health center, day care, A/E department, etc.)
5.20 All patients have to arrange their own transport when going for OOP.
5.21 The patient or the paying party (e.g. sponsor, insurance company, etc.) is responsible
for the bed charges (if any) when the patient is out on pass.

6. Procedures
6.1 Before granting OOP for a patient, the treating doctor should first consider whether
hospital discharge and outpatient follow up is more appropriate. Also, the doctor should
consider if any injectable medication can be changed to oral ones.
6.2 OOP should be planned as much as possible, so as not to interfere with administration
of medications or other therapeutic procedures.

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 6.3 OOP should be authorized by the treating doctor and managed by the ward nurses.

6.4 Procedures before patient leave: before the patient leaves the hospital, the ward nurse
should do the following:
6.4.1 Make sure that the OOP form is duly filled and signed by all relevant parties.
6.4.2 Make sure it is safe to let the patient go (e.g. acceptable level of consciousness,
stable vital signs, etc.).
6.4.3 Give the patient a copy of the OOP form and any relevant reports if the patient
has to follow up at any health care facility for treatment while on OOP.
6.4.4 Make sure the patient has his/her medication and consumables (if any) when
leaving the hospital (the patient should preferably be given medications for one
extra day in case of OOP extension).
6.4.5 Make sure the patient/attendant has the contact number of the hospital/ward in
case they need to contact the hospital for any reason.
6.4.6 Remove any intravenous line, tube, or material the patient is not authorized to
leave with.
6.4.7 Explain to the patient the following:
6.4.7.1 A bed will be reserved for the patient until he/she is back but there is no
guarantee that the patient will return to the same bed.
6.4.7.2 To keep the wristband on while in OOP.
6.4.7.3 How to use and keep the medications safely.
6.4.7.4 How to act and where to go in case of any medical emergency.
6.4.7.5 The activity level permitted.
6.4.7.6 Any other instructions related to the patient’s condition or given by the
doctor.
6.4.7.7 The authorized period for OOP and the procedures that will be taken in
case of not returning to the hospital within the specified time of return.

6.5 Procedures after patient leave: after the patient leaves the hospital the ward nurse
should do the following:
6.5.1 Document in the patient's medical record the time of patient's departure, the
procedures done, and the instructions given.
6.5.2 Inform the hospital bed manager/discharge planner about patient's leave.

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 6.6 Procedures after patient return: when the patient returns from OOP the ward nurse
should do the following:
6.6.1 Assess and document the patient’s status.
6.6.2 Record any complications or symptoms the patient developed while on OOP.
6.6.3 Check if the patient has brought back any medications or consumables and their
validity.
6.6.4 Verify whether the medications were administered as instructed.
6.6.5 Check availability of enough medications for the patient in the medication
drawer, otherwise ask the doctor to prescribe them again.
6.6.6 Inform the doctor and bed manager/discharge planner about patient's return.

6.7 Going home with a peripheral IV cannula:

6.7.1 A patient going out on pass may be allowed to leave the hospital with a peripheral
IV cannula if there is a strong clinical indication for keeping it and after taking
all necessary precautions to ensure patient safety (including giving the needed
advice on how to take care of the cannula).
6.7.2 If the patient does not want to go home with a cannula, the cannula has to be
removed after explaining to the patient that he/she will need to be cannulated
every time an intravenous therapy is administered while out on pass and when
returning back to the hospital.
6.7.3 Before a patient goes out on pass with IV cannula, the nurse should make sure the
cannula is functioning, secured in place, and does not need to be changed until
the patient is back.
6.7.4 The staff nurse should also explain to the patient the following:
6.7.4.1 The importance of avoiding injecting any material through the cannula
other than the prescribed intravenous medication(s).
6.7.4.2 The signs and symptoms that the patient should monitor at the cannula
site (e.g. redness, swelling, pain, leaking of fluid or blood, etc.).
6.7.4.3 How to keep the cannula dressing clean and dry (e.g. avoiding soaking
the cannulated arm in water, patting the dressing dry if it gets wet, etc.).
6.7.4.4 How to protect the cannula from knocks and being pulled (e.g. avoiding
wearing watch or jewelry at the cannula forearm, taking extra care when
changing clothes, etc.)

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 6.7.4.5 What the patient should do if the cannula accidently comes out (e.g. not
trying to reinsert the cannula, applying finger pressure over the cannula
site, etc.).
6.7.5 The nurse should also document in the patient's medical record all details of
patient's leave with the IV cannula and the instructions given.
7. Patient failure to report back
7.1 In case the patient fails to report back to the ward/unit in the specified date and time of
return, the following procedures should be followed:
7.1.1 The ward nurse should inform the bed manager/discharge planner about patient’s
delay.
7.1.2 The bed manager/discharge planner or any authorized person (e.g. the PRO)
according to the hospital local policy will call the patient asking about the reason
for delay and the expected time of arrival.
7.1.3 If the patients says he/she will arrive within the next 4 hours, then the bed
manager/discharge planner should inform the ward nurse of the expected time of
arrival and no further procedures are required.
7.1.4 If the patients says that he/she will arrive after 4 hours, then the bed manager/
discharge planner should discuss the case with the treating doctor to decide
whether to wait for some more time or discharge the patient.
7.1.5 If the doctor decides to wait for some time, then the doctor should specify the
time after which the patient has to be discharged and to document that clearly in
the patient's medical record.
7.1.6 If the doctor decides to discharge the patient, then the usual discharge procedures
are to be followed. The doctor should prepare a discharge summary including the
OOP details and the reason for discharge, as well as the usual information about
the patient’s condition and treatment. The doctor should also prepare an incident
report of the event along with the discharge summary.
7.2 In case the bed manager/discharge planner gets no response after several phone calls
over the course of 4 hours on the patient’s phone and the alternative number, the patient
is to be discharged, and the same discharge procedures explained above should be
implemented.
7.3 In all cases where a child patient has to be discharged due to failure to return back from
an OOP, the case has to be reported through the child protection hotline (1100) and the

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 child protection committee in the governorate has to be informed of the incident to
follow up the case.
7.4 Whenever a patient is discharged due to failure to report back from OOP, the
discharging doctor and concerned staff should make sure that all necessary
arrangements for safe discharge of the patient are implemented. The patient should be
given the opportunity for easy access to the A/E department or follow up in the OPD
(where applicable). Also patient's medications can be prescribed and made available to
him/her (based on last assessment and best doctor's judgment) in case the patient
decides to come and collect them. Such procedures should be managed by some
policies inside the hospital to ensure continuity of patient care.
7.5 Appendix 2 shows an algorithm of the steps that have to be followed when a patients
fails to return from OOP.

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8. Document history and version control

Version Description Review Date

01 Initial Release November 2025

9. Related Documents
There are no related documents for this policy

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10. References

Title of book/ journal/ articles/ Website Author Year of publication Page

Inpatient Out on Pass Policy and Procedure, Mr. Ahmed 2018 -
Ibra Hospital (IH/ND/P&P/096/Vers.01) Al Falahi,
Unit Head of
Ambulatory
Area
Out On Pass (inpatient leave of absence) Directorate 2018 -
from Hospital (DRAFT) General of
Nursing
Affairs,
MOH

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 11. Attachments
Appendix 1: Out on Pass Form

‫سلطنة عمان‬ HOSPITAL No: ……………………………..............

NAME: ………………………………………………
‫وزارة الصحة‬ AGE: ………SEX: ………NATIONALITY: ………
SULTANATE OF OMAN UNIT/WARD: …………………………. BED: …….
MINISTRY OF HEALTH HOSPITAL: …………………………………………

Out On Pass (OOP) Form ‫استمارة خروج مؤقت‬

OOP Details: :‫تفاصيل الخروج‬
From: Date Time am/pm ‫مساءا‬/‫صباحا‬ :‫الوقت‬ :‫من تاريخ‬
To: Date Time am/pm ‫مساءا‬/‫صباحا‬ :‫الوقت‬ :‫إلى تاريخ‬

OOP Reasons: :‫أسباب الخروج‬

………………………...................................... ......................................................................................
………………………...................................... ......................................................................................
Special Instructions (if any): :)‫تعليمات خاصة (إن وجدت‬
………………………...................................... ......................................................................................
………………………...................................... ......................................................................................

I, the undersigned, have my doctor's approval ‫أقر أنا الموقع أدناه بأني قد حصلت على موافقة الطبيب للخروج من‬
for an absence from the hospital in the date and ‫ كما أقر‬.‫المستشفى بشكل مؤقت وفي التاريخ والوقت المحددين أعاله‬
time specified above. I acknowledge that the ‫ وعليه‬،‫بأن الخروج جاء بناءا على طلبي ولألسباب المذكوره أعاله‬
absence is based on my own request and for the ‫فإني ال أحمل الطبيب أو المستشفى أي مسؤولية عن ما قد يحدث لي‬
reasons mentioned above and therefore I .‫خالل فترة غيابي عن المستشفى‬
release the doctor and hospital from all ‫كما أقر بأني أتفهم أنه في حال عدم عودتي إلى المستشفى في التاريخ‬
responsibility for any events may happen to me ‫والوقت المحددين فإنه قد يتم ترخيصي من المستشفى وبأني مسؤول‬
during my absence from the hospital. I also .‫بشكل كامل عن رسوم السرير (إن وجدت) خالل فترة غيابي‬
acknowledge and understand that if I do not
return to the hospital at the specified date and
time I may be discharged from the hospital and
I am responsible for the bed charges (if any)
during my absence.

Date: / / Time: :‫الوقت‬ / / :‫التأريخ‬

Signature ‫ التوقيع‬Name & Staff Number ‫اإلسم والرقم الوظيفي‬
...................................................................................... :‫المريض أو ولي األمر‬
.................................................... :)‫صلة القرابة (لولي األمر‬ Patient or person
Relationship (for the authorized person) authorized to sign
...................................................................................... ‫الطبيب‬
Doctor
...................................................................................... ‫الممرض‬
Nurse

MoH/DGSMC/P&P/024/Vers.01 December 2022 Page 13 of 14

Appendix 2: Algorithm of Steps to Follow when Patient Fails to Return from OOP

Patient fails to report back

within the specified time frame

Inform the bed manager/discharge planner to call the patient

No response after several Patient will arrive Patient will arrive

calls over the course of 4 hrs. after 4 hrs. within the next 4 hrs.

Discuss with the - Inform the ward nurse to wait

Discharge the
treating doctor - No further procedures required
patient

Doctor decide to wait for some Doctor decides to discharge

more time the patient

- Doctor to specify the

Doctor to prepare a
allowed waiting time if allowed time passed discharge summary &
- Doctor & nurse to document
incident report
it in patient's medical record

Discharge the
patient

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