Keep the licence and its permits, a file for every member of staff, written policies and SOPs, maintenance and vaccination records, and a complete record for every patient. DGPHE's manual lists them, and the final inspection checks the core policies before a licence is issued.
The policies needed before a licence
DGPHE's licensing manual asks for a medical director and documented policies for infection control and hazardous waste, medication management, the patient health record, patient transfer and the emergency action plan, and radiation safety where it applies. The Charter of Patients' Rights and Responsibilities must be posted in Arabic and English, with the opening hours and a price list of the major services.1
The records DGPHE lists
| Record | What it holds |
|---|---|
| Licences | The MOH licence, the municipality and civil defence licences, and the approved, stamped drawings |
| Contracts | Be'ah medical waste, cleaning and laundry, and preventive maintenance for equipment |
| Staff files | Contract, qualifications, licence, BLS or ACLS, signed job description, appraisal, induction and CPD |
| Clinical policies | SOPs, the inoculation policy, the medical record and referral policy, the GCC infection control manual |
| Operations | Minutes of meetings, staff vaccination records and the nurses' duty roster |
The Executive Regulation adds a register of every criminal incident or death involving a patient or companion, reported to the Ministry and the nearest police station, and an electronic health information system to the Ministry's approved standards.2 The Medical Record Documentation Guideline adds a master patient index, patient, operation, birth and death registers, and an approved list of abbreviations.3
- Start from DGPHE's list. Each record in the manual, with a named owner.
- Write the five core policies. Infection control, medication, the health record, transfer and emergency, and radiation where it applies.
- Open a file for every professional. Licence, life support certificate, job description, appraisal and CPD.
- Diary the expiry dates. Licences, contracts and certificates, each with a reminder before it lapses.
- Review once a year. Sign and date every policy, and record what changed.
- Document ______ Owner ______
- Version ______ Approved on ______
- Expires or next review ______
- Where it is kept ______
- Last checked by ______ On ______
Questions
How does wai show our policies are followed?
wai keeps the clinical and patient records your policies govern, and the audit trail that shows they are followed.
In which languages must consent forms be?
Arabic and English, under DGPHE's manual.
Do we need a medical director?
Yes. DGPHE's manual lists appointing a medical director among the conditions for the licence.
Sources
- 1Ministry of Health, Oman, 2024Licensing Regulations for Private Health Establishments Manual, MoH/DGPHE/F/013/Vers.003, August 2024Read source
- 2Qanoon.om, 2024Ministerial Decision 231/2024 issuing the Executive Regulation of the Law Regulating the Practice of the Medical Profession and Allied Medical ProfessionsRead source
- 3Ministry of Health, Oman, 2025Medical Record Documentation Guideline, MOH/DGPHE/GUD/016/Vers.02, March 2025Read 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.