Which documents and policies does MOPH expect a Qatar facility to keep?

The signed Patients' Bill of Rights undertaking, a consent policy that documents every consent or refusal in the record, a complaints route, every practitioner's DHP licence, sterilisation records and a permit for processing health data. Keep each with an owner and a review date.

The documents MOPH names

MOPH's guidelines require the medical director to read, sign and send the Bill of Rights undertaking to MOPH and keep a copy, and to make sure every practitioner and administrative employee knows the Bill.¹ The Bill itself says a patient's consent or refusal must be documented in the medical record, and gives patients the right to a copy of their reports under the facility's internal policy.²

The rules on the Bill itself

No clause of the Bill may be amended, added or deleted without approval from the Fitness to Practice Section, though a facility may add its own logo beside MOPH's.¹ By signing the undertaking, the facility takes full responsibility for any breach.³ Fitness to Practice treats care given without consent, under MOPH's Informed Consent Policy, as a conduct complaint, beside access to records and breaches of confidentiality.⁴ Health data may only be processed after permission from the competent department.⁵ MOPH also asks facilities to keep their data current on the Facility Licensing Portal.⁶

1. Sign the undertaking. The medical director reads the guidelines, signs, sends the original to MOPH and keeps a copy on file.
2. Write the consent policy. Who takes consent for what, how it is explained in a language the patient understands, and where consent or refusal is written.
3. Write the records release policy. How a patient asks for a copy of their reports, who approves it, and how fast it goes out.
4. Write the complaints route. Practitioner, then medical director, then MOPH through the Governmental Health Communication Center.
5. File every licence. Each practitioner's DHP licence, its scope and its expiry, checked monthly.
6. Apply for the data permit. Under Article 16 of Law No. 13 of 2016, before health data is processed.

1. Document ______ Version ______
2. Required by ______
3. Owner, name and role ______
4. Approved on ______ Next review ______
5. Where staff can read it ______
6. Where the evidence of use is kept ______

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Questions

Who signs the Bill of Rights undertaking?

The medical director, who sends it to MOPH and keeps a copy. The facility takes full responsibility for any breach.

Can we change the wording of the Bill?

No clause may be amended, added or deleted without approval from the Fitness to Practice Section, though you may add your own logo beside MOPH's.

Does a clinic need a permit for health data?

Under Article 16 of Law No. 13 of 2016, health data is personal data of a special nature, processed only after permission from the competent department.

Sources

1. 1Ministry of Public Health, Qatar, 2021Guidelines for Implementation of Patients' Bill of Rights and Responsibilities in all Healthcare Facilities in the State of QatarRead source
2. 2Ministry of Public Health, Qatar, 2021Patients' Bill of Rights and Responsibilities, EnglishRead source
3. 3Ministry of Public Health, Qatar, 2021Undertaking for Facilities, Patients' Bill of Rights and ResponsibilitiesRead source
4. 4Ministry of Public Health, Qatar, 2019What kinds of complaints does the Department deal with?Read source
5. 5National Cyber Security Agency, Qatar, 2016Law No. (13) of 2016 on Protecting Personal Data Privacy, English text, Article 16Read source
6. 6Ministry of Public Health, Qatar, 2024Circular No (HFD/2024/18), updating healthcare facilities data via the Facility Licensing Portal (FLI)Read source

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