Policies,Clinical,UW Health Clinical,General Care and Procedures,Procedures

Inpatient Absence Policy (2.3.27)

Inpatient Absence Policy (2.3.27) - Policies, Clinical, UW Health Clinical, General Care and Procedures, Procedures


Policy Title: Inpatient Absence Policy
Policy Number: 2.3.27
Category: UW Health
Type: Inpatient
Effective Date: May 26, 2017


To establish standards for granting inpatients at UW Health hospitals off unit absence from inpatient units.

UW Health recognizes the benefits of being outdoors and the positive impact fresh air and sunshine can
have on a patient’s overall wellbeing. Accordingly, access to the outdoors, to the extent possible, should be
considered an important part of the plan of care for eligible patients with long lengths of stay.

UW Health respects the diverse cultural needs, preferences, and expectations of the patients and families it
serves to the extent reasonably possible while appropriately managing available resources and without
compromising the quality of health care delivered.


A. Brief off unit absence: An inpatient leaving the unit but remaining on hospital grounds for an anticipated
time of one hour or less.
B. Hospitalized Patient Pass: A longer authorized absence from the unit off hospital grounds for up to five (5)
C. Non-therapeutic leave is not covered under this policy. It is used for billing purposes for Medicare patients.
D. Surrogate decision-maker as used in this policy is defined as an individual authorized under Wisconsin law
to consent for a patient. Refer to UWHC policy #4.17, Informed Consent.


A. Brief Off Unit Absence
i. UW Health recognizes that as part of their course of treatment medically stable patients may
request a brief off unit absence during their admission. In order to permit certain patients to be
temporarily absent from their unit without being discharged, UW Health has established criteria for
brief off unit absences. For inpatients who have isolation ordered, refer to UW Health clinical policy
#4.1.8, Standard Precautions and Isolation and UWHC policy #13.06, Precautions for
Immunocompromised Patients (Protective Precautions).
ii. Patients and families are informed upon admission about expectations for patients wishing to take
a brief off unit absence. For patients requesting to use tobacco products, refer to UW Health
administrative policy #1.41, UW Health Smoke Free/Tobacco Free Workplace.
iii. Patients who have received opioids, benzodiazepines, or other sedatives are required to remain on
the inpatient unit for at least one hour after administration and have returned to baseline sedation
score. If a patient refuses or leaves without notifying staff, the patient may be designated absent
without official leave and/or discharged against medical advice (AMA). See UWHC policy #4.19,
Discharge Against Medical Advice/Elopement from Hospital.
iv. If the patient is receiving an infusion of a controlled substance, such as through patient controlled
analgesia (PCA) or patient controlled epidural analgesia (PCEA), the patient must notify staff that
they are leaving the unit so the infusion can be stopped and disconnected. The attending physician
will be notified.
v. Patients who fail to return to the unit at the designated time may be considered absent without
official leave. In the event the patient does not return the nurse notifies the provider and the nurse
manager (or their respective designees) to discuss discharge procedures, if appropriate. The
attending physician will be notified.
vi. A brief off-unit absence does not require a provider order, except on In-Patient psychiatry (refer to
Nursing Patient Care policy #8.32A, Privileges for Inpatient Psychiatry (Adult)).
vii. Each patient is required to notify staff before leaving their inpatient unit. Minors require parental
consent to leave the inpatient unit, unless accompanied by a clinical team member. Parents/
surrogate decision-makers must notify staff before a minor or an incompetent patient leaves their
inpatient unit.
B. Hospitalized Patient Pass (up to five hours)

Policy Title: Inpatient Absence Policy
Policy Number: 2.3.27

i. In the rare event that a patient/surrogate decision-maker is requesting to leave the hospital grounds
for longer periods of time to attend to personal affairs (e.g., attend funeral) or the healthcare team
has determined a need for a pass (e.g., practice with car transfers), a hospital patient pass may be
granted by their provider for an absence up to five hours if determined to be medically appropriate
and safe.


A. A hospital patient pass may only be issued under a provider order, which must specify (i) the length of time
the patient is authorized to be absent from the nursing care unit, (ii) the reason for the absence, and (iii) any
special instructions related to the pass.
B. A Patient Absence Request form must be completed and signed by the attending physician (or designee)
and the patient (or surrogate decision-maker). A copy will be given to the patient/surrogate decision-maker
and will be scanned into the patient’s medical record.
C. Hospital patient passes may not be issued to:
i. Minor patients without parental consent or incompetent adults without surrogate decision-maker
ii. Patients scheduled for surgery after their preoperative evaluation has been completed.
D. Nursing staff must assess and document the patient’s status both when the patient leaves and returns to the
E. The Patient Absence Request form informs patients that failure to return to the unit within their expected
return time may result in the patient being discharged against medical advice (AMA) and losing their bed.
Prior to leaving, unit staff should remind the patient that his or her bed will only be held for the duration of the
pass and document the discussion in the medical record. Patients who fail to return will be discharged AMA
(see UWHC policy #4.19, Discharge Against Medical Advice/Elopement from Hospital).
F. The patient’s medical record will continue to be an open encounter and documentation will continue upon
the patient’s return.


A. Consent for a pass for minor patients and adult patients that lack decision-making capacity must be obtained
from the surrogate decision-maker in writing or verbally (with two witnesses) if the individual to whom the
patient is being released is different from the surrogate decision-maker. The individual's name and contact
information must be documented in the patient's medical record.


A. It is preferable that hospitalized patient passes should be planned so as to not interfere with medication
administration. However, providers may approve late or missed doses of prescribed medications as
necessary and UW Health will provide oral medications when needed. No controlled substances may be
dispensed for the pass.
B. If necessary, arrangements may be made for a supply of medication(s) while the patient is gone from the
hospital. A pharmacist will dispense medications from the hospital supply for the duration of the pass.
C. A medication chart listing the medication name, dosing instructions and time due will be issued by the
pharmacist will instruct the patient/surrogate decision-maker /authorized adult to document the time each
medication is taken/administered while on pass.
D. Nursing will ensure that the medications that are due while the patient is on pass are left outstanding in the
electronic medication administration record. Upon return, the RN verifies if meds were taken and documents
in the medical record with the MAR action of give, and enter “self-admin while on pass” in the comments
field. The administration time should then be edited to reflect the actual time that the patient took the meds.
Any unused medications will be returned to the pharmacist.


A. Patient/surrogate decision-maker /authorized adult should be instructed to alert the Nursing Staff on the unit
upon return. Nursing personnel notify all other appropriate departments upon patient's return. When the
patient returns from pass, the patient is to be seen by nursing personnel who document on the Absence
Request Form and in the medical record the date and time of return and any problems encountered during

Policy Title: Inpatient Absence Policy
Policy Number: 2.3.27

the pass.

If the patient does not return from pass at the designated date/time, the nursing unit will attempt to contact
the patient/surrogate decision-maker /authorized adult who took the patient on pass to determine if the
patient is returning. If the patient does not return, the physician will be notified and the patient will be
considered discharged AMA (see UWHC policy #4.19, Discharge Against Medical Advice/Elopement from


UW Health Patient Absence Request


Author: Director, Nursing Quality & Safety
Senior Management Sponsor: SVP/Chief Nurse Executive
Reviewers: Director, Risk Management; Nurse Manager, Inpatient Psychiatry; Nurse Manager, General
Medicine & Geriatrics; SVP/Associate Chief Medical Officer; Nursing Coordinator – Inpatient; Director, UW
Health Home Care and Coordinated Care; Director, Pediatric Nursing
Approval committees: UW Health Clinical Policy Committee, Medical Board
UW Health Clinical Policy Committee Approval: April 17, 2017

UW Health is a cohesive, united and integrated academic medical enterprise comprised of several entities.
This policy applies to facilities and programs operated by the University of Wisconsin Hospitals and Clinics
and the University of Wisconsin Medical Foundation, Inc., and to clinical facilities and programs
administered by the University of Wisconsin School of Medicine and Public Health. Each entity is
responsible for enforcement of this policy in relation to the facilities and programs that it operates.


Peter Newcomer, MD
Chief Clinical Officer

J.Scott McMurray, MD
Chair, UW Health Clinical Policy Committee


UWHC policy #13.06, Precautions for Immunocompromised Patients (Protective Precautions)
UWHC policy #4.17, Informed Consent
UWHC policy #4.19, Discharge Against Medical Advice/Elopement from Hospital
UW Health administrative policy #1.41, UW Health Smoke Free/Tobacco Free Workplace
UW Health clinical policy #4.1.8, Standard Precautions and Isolation
Nursing Patient Care policy #8.32A, Privileges for Inpatient Psychiatry (Adult)
Recommendations for Addressing Non-Prescribed Drug Use of Dangerous Drug Diversion in the Inpatient


Version: Revision
Last Full Review: May 26, 2017
Next Revision Due: May 2020
Formerly Known as: Hospital Administrative policy #7.29, Leave of Absence or Pass for Inpatients