BY. Sis. NURZIA J. PASIL QPSD-risk management officer Meeqat General Hospital Complex madinah, KSA

1. Absconded
Out on pass

2. 1. Out on pass is an inpatient who is temporarily absent from a
ward, by arrangement, for not more than 48 hours because:
1. (S)he has been allowed to go home temporarily.
2. (S)he has been transferred to another hospital and is expected to
return.
3. (S)he has been transferred from a long stay specialty to another
specialty in the same hospital and is expected to return
2. DAMA- Discharge Against Medical Advised
1. Is a “self-discharge” or “discharge at own risk” occurs when a
patient chooses to leave the hospital before the treating
physician recommends discharge.
THEY HAVEN’T BEEN SEEN YET, BUT THE FACILITY HAS TOUCHED THEM., THEY SIGNED IN AND THEN THEY
DECIDED TO LEAVE, ALL OF THESE CAN BE CONSIDERED DAMA.
2. If an out on pass patient failed to come on specified time
decided by his physician or his/her designee.
3. Absconded- Patient who left the hospital without:
1. Proper discharge procedures.
2. Asking the physician or nurse’s permission out on pass.

3. POLICy:
-Is to provide proper steps, prompt and sufficient
response to the situation, guide in place that formalize
how staff respond to a patient refusal, including careful
documentation processes and follow-up when patient;
1. By arrangement, leave the hospital at specified time that is not more than 48
hours. OUT ON PASS
2. If an out on pass patient failed to come on specified time decided by his
physician or his/her designee. (DAMA)
3. When a patient chooses to leave the hospital before the treating physician
recommends discharge. DAMA
4. Patient who left the hospital without proper discharge procedures.
(ABSCONDED)
-It provides guide for the staff in documenting accurate
assessment of
RISK, criteria and legal responsibility on the patient file.
-Avoid confrontations and respect a patient’s right to
refuse- Offer alternatives to the care being refused.

4. Out on pass
1. Patient must pass through the admission procedure and completed preoperative workup before allowed to
leave the hospital.
2. A therapeutic pass may only be issued under a provider order, after
assessment that must specify :
2.1. The length of time the patient is authorized to be absent from
the unit based upon assessment of his/ her medical condition and
intervention he/she might need to come back before leaving the
hospital.
2.2. The reason for the absence
2.3. Any special instructions related to the pass.
3. Upon the patients return, department nurse staff would then chart
the time returned, who they were with when returning, & general
condition .
4. The patient must be informed that failure to return to the unit
within their expected return time may result in the patient being
discharged as DAMA and losing their bed.

5. 1. A patient that has been seen and haven’t been seen yet, but
the facility has touched them, they signed in and then they
decided to leave, all of these can be considered DAMA.
DAMA
2. If the general condition of the patient is critical
and there is life threatening clinical condition,
the patient relation personnel and social worker
will be informed to support the treating
physician and explain to the patient and his / her
family who wish to leave the hospital and
document these reasons in the patient file.
3. The hospital must reconcile any outstanding
diagnostics results: Any tests were ordered, the
hospital is still responsible for checking the results
to be sure nothing serious was identified and if there
is significant results came out after patient
discharge, the patient must be contacted and
informed

6. 3. Steps to take when patient verbalized DAMA plan:
1. The nurse must notify the attending physician or resident on-duty
regarding patients desire to go for DAMA
2. If the patient(and or family) cooperates and his / her clinical condition
is not critical and requesting to leave against medical advice, the reasons
behind his / her leave has to be discussed if can be solved and continue
his / her management by the treating physician together with social
worker.
3. If the same patient still insisting to leave the department for personal
reasons, he / she will sign the General Consent (DAMA) Form, the
treating physician, nurse must countersign his /her signature and
signature from administration on duty or patients affair for clearance.
4. The discharge summary should includes all patient medical and
surgical data, the plan of treatment, bring home medications ordered by
the treating physician and any other recommendations and how to
communicate the hospital in case of top emergency.

7. Absconded- Patient who left the hospital without:
2.1.1. Proper discharge procedures
2.1.2. Asking the physician or nurse’s permission
out on pass.
Risk factors of absconded patient:
1. There is a link between absconding and to serious self-harm, lesser extent
to violent behavior.
2. Absconding can also result in serious self-neglect which can lead to
death.
3. Absconding may lead to catastrophic loss of confidence by relatives who
expect the hospital to be a 'place of safety'.
4. When things do go wrong, there is a possibility that legal action may
be taken

8. Absconded patient can be categorized into:
1. HIGHRISK-patient is an individual who present a risk to themselves and/or others.
1.1. Rapid deterioration (life saving) in physical condition.
1.2. Those patients who are an immediate risk and have a significant likelihood to
suffer harm to them as an individual or as a threat to others.
1.3. An extremely young or an extremely old person.
1.4. Patient who is assessed as likely to attempt significant self-harm or suicide.
1.5. A patient who does not have the mental capacity to make a decision
1.6. At risk of spread of infection to community( eg. MERS)
2. Medium risk- is an individual who not considered to present any danger to
themselves and/or others.
2.1. A little risk of deterioration in their physical condition due to being outside the
hospital.
2.2. A patient that is assessed as likely to come to harm without medical assistance.
3. Low risk patient is not considered to present any danger to either themselves or
other.
These are patients who are willingly absent, but are able to function adequately
without assistance and are unlikely to come to harm under normal circumstances. It
would also cover cases where despite consideration of known risk factors, there are
still no grounds for believing the missing person is likely to come to harm.

9. RESPONSIBILITIES:
1. THE STAFFNURSE:
1.1. ENSURE THAT PATIENT IS ABSCONDED AND DETERMINES THE EXACT
TIME OF DISCOVERING THAT THE PATIENT ABSCONDED OR THE TIME OF
RETURN.
1.1. TO INFORM THE RESPONSIBLE PHYSICIAN THAT THE PATIENT WAS
ABSCONDED/MISSED.
1.2. TO INFORM DIRECT LINE MANAGER.
3.1.4. DOCUMENTS INCIDENT REPORT (OVR FORM).
3.1.5. DOCUMENT WHAT IS HAPPENED IN THE PATIENT’S FILE
2. DIRECTLINEMANAGER:
2.1. TO INFORM THE SECURITY AND START SEARCHING FOR THE PATIENT.
2.2. TO INFORM THE DIRECTOR ON-DUTY/ADMINISTRATOR.
2.3. TO INFORM SOCIAL WORKER AND OR PATIENT’S RELATIONS.
2.4. TO INFORM THE POLICE, IF INDICATED.
2.5. TO FILL THE ABSCONDED FORM .
3.PHYSICIAN IN CHARGE
3.1. TO DETERMINE HIGH-RISK PATIENT, NEEDED TO BE ALLOCATED AND
RECALL.

10. 3.2. To ensure full record in the patient’s medical record.
3.3. To complete the absconded form.
4. Socialworker/Directorondutyin pm/nightshiftandweekends.:
4.1. To collect all personal information.
4.2. To contact the relatives and inform them about the
situation.
4.3. To discuss with the patient the reasons of leaving and
the ability to back again.
5. Headof security(Policeofficer):
5.1. Responsible for patient safety and medical legal
implication.
6. AdmissionOfficer/Reception(SelfResources
Administration):
7.1. Provides patients information and admission status.

11. POLICY:
1. The policy applies to all inpatients across MGH.
2. Patient is categorized as absconded if he / she is not on bed for one
(1) hour after thorough search by Nursing Staff and Security Officer
2.1. Bed is blocked for six (6) hours. Patient will be discharged
after 6 hours.
2.2. Discharge should be accomplished by the Physician as soon as
possible.-
3. Determine the high-risk patient need to be allocated and recall
again to ED.
Procedures:
1. Determine absconded- If the patient identified out of bed/missing
after one (1) hour.
2. Stepsto be taken:
2.1. If the patient high risk: The charge nurse will assign some staff
nurse and security, to search the patient immediately without waiting
for return of the patient by himself, in the corridors, bathrooms,
visiting his neighbor patients, and external to the ED or hospital unit.

12. 2.2. If the patient moderate or low risk:
2.2.1. The nurse who discovered the absconding patient will report the
incident to his/her direct line manager.
2.2.2. The charge nurse can wait for one hour to alert the security and
start searching of the patient.
2.2.3. At the same time gather all available information concerning the
situation
3. Reviewthe situationof the patient:
4.1.History of previous event of going absconded either from hospital
or at home, it will be necessary to check patient record or information
if relatives are available.:
4. Recallback thepatient to ED/Unit:
4.1. The social worker and patient relationship will collect all the
personal information of the patient and RECALL patient back to
the hospital.
4.2. If the patient informed, a maximum of six hours will be allowed for
him or his relative to return from the time he/she leaves the hospital

13. 5. Police involvementin all casesof absconded:
5.1. Criteria before contacting the police service:
1. High risk, Critical patient level I & II.
2. Confused, dementia, aged, or drug addict.
3. Female, child and in-competent patient.
4. Disabled or handicapped.
5. Leaving the hospital with central or peripheral lines.
6. History of self-harming.
5. 2. Contacting the police as the correct course of action must be decided by
both charge nurse and concern doctor due to some legal issues.
6. Hospitalright: The hospital will not be responsible
6.1. For any sequel or complication in this condition
6.2. Any illegal act done in this period.
7.Patientswho return:
7.1. The patient must be seen and re-assess by the doctor.
1. Re-assessment will be done and previous management plan will be
changed base in the light of new clinical evaluation.

14. 2. Patients who absconded but who either return voluntarily or brought back by
the police back to emergency department and or unit should be considered as:
2.1. High risk for further episodes of absconding and their clinical assessment
must be priorities.
2.2. Patient may have changed condition due to:
2.2.1. Ingestion 2.2.2. Alcohol intake
2.2.3. Drugs 2.2.4. Abuse (self-harm) etc.
8. Prevention of absconding:
1. If the patient is adamant to leave even after all effort given by medical staff to stay,
then discharge patient with option to choose against medical advise ( ref to policy of
DAMA) but if the patient still to refuse the said option, then patient is considered as
ABSCONDED.
9. Documentation:
1. Complete ABSCONDED form. Make sure all concerned staff in the designated
area and space has been filled up with their side and signed.
2. Only after obtaining discharge order from the physician after 6 hours discharge
is confirmed, then nurse must release now the patient record from the unit
system as ABSCONDED.
3. Write an incident report (OVR).

17. 2. Authentication of Medical Record Entries:
1. Correctly identify patients should be made prior to
documenting
2. Initials can only be used on medical record forms
approved by the organization,such as flow sheets,
medication records or treatment records.
3. All entries shall be signed or initialed/authenticated by
the provider. Signatures must include first name or
initial, last name, and employment/status (e.g., SOD) or
licensure status (e.g., M.D.). Initials alone are not
acceptable
4. For authenticating paper medical record documentation,
handwritten signatures may be accompanied either by
the author legibly writing his/her name in block print or
by the use of a name stamp accompanied by a signature.

18. 5. Users shall not share their account(s), passwords, (PIN),
Security tokens (e.g., Smartcard), or similar information
or devices used. Individual identified by the electronic
signature or method of electronic authentication is the
only individual who may use it, as it denotes authorship
of medical record documents in electronic medical
records.
3. Timing and Dating of Entries:
1. All entries must be timed and dated.
2. Record times based upon 24-hour military time.
3. It is recommended that entries be recorded as closely
as possible to the time of the encounter.
4. It is recommended that all paper-based entries in the
papers must be in black or blue ink . Entries should not
be made in pencil.

19. “If it wasn’t written down, it didn’t happen.”
4. Chronological Entries:
1. It is strongly recommended that all materials in the
medical record be organized in a chronological and
systematic manner.
2. An entry should never attempt to preserve the
chronological order of the interaction/intervention date
and time by entering an artificial or inaccurate
documentation date and time.
3. When clinical documentation is entered out of
chronological order, it is a 'late entry' and shall identify:
5. Legibility and Clarity:
1. Regulations require that medical records be legible.
2. Do not use text message language in documentation
3. Do not use unapproved abbreviations.
4. Document in blue or black ink; no felt-tip pen.

20. .
Electronic documentation with these
systems can help decrease documentation
deficiencies and errors, as well, since an
EHR system’s prompts remind a nurse to

21. 5. Every entry must be dated, timed, and signed (can be
initial).
6. For non- computer documentation of FLOWSHEETS:
a. Place an “√” in the boxes that apply or circle the
appropriate responses.
b. If a subject on the flowsheet requires a written
response, and the response is not applicable, write
“NA” in the corresponding space.
7. Documentation of a NARRATIVE NOTES:
1. Each page (front and back if two-sided) must be
dated and notes must have the first initial, full last
name, and credentials of individual documenting on
the sheet.

22. 6. Error Correction Process:
1. At no time is it permissible to obliterate or remove a
previous entry in the medical record (paper or
electronic).
Note: When using late entries, document as soon as possible. There is no limit
to writing a late entry, however, keep in mind that the more time passes,
the less reliable the entry becomes.
a. When an error is made in a paper-based medical
record entry, the following error correction
procedures must be followed:
i. Draw a line through the entry. Make sure the
inaccurate information is still legible.
ii. Do not write error on the line.
iii. Sign and date the entry.
vi. Do Not obliterate or otherwise alter the original
entry by blacking out with marker, using whiteout
or writing over an entry.

23. b. When an error is made in an electronic medical
record entry, the following error correction must be
followed:
i. An “Addendum” note should be dictated or typed
referencing the incorrect documentation or dictation no.
ii. When correcting or making a change to an entry in the
computerized medical record/ (EHR), the original should be
viewable, the current date and time should be entered, the
person making the change should be identified, and the
reason should be noted.
7. System Downtime (Electrical Shutdown):
1. Refer to department downtime protocol.
8. Use of Cloned Documentation in the Electronic
Medical Record
1. Previously entered data, when used in a new note, should
always meticulously updated and edited.

24. 9. History and Physical
1. A History and Physical Examination (H&P) is required for all
hospital admissions (adequate for the duration of the hospital
stay).
10. Do not falsify any document.
1. Creation of purposely inaccurate entries or
documentation
2. Back-dating entries
3. Pre-dating entries

25. IPSG – 6 (REDUCE THE RISK OF PATIENT HARM RESULTING FROM
FALLS)