§ 7–1305.12. Maintenance of records; information considered privileged and confidential; access; contents.
(a) Complete records for each person shall be maintained and shall be readily available to professional persons and to the staff workers who are directly involved with the particular person and to the Department on Disability Services without divulging the identity of the person. All information contained in a person’s records shall be considered privileged and confidential. The person’s parent or guardian who petitioned for the commitment, the person’s counsel, the person’s advocate for a person with an intellectual disability and any person properly authorized in writing by the person, if such person is capable of giving such authorization, shall be permitted access to the person’s records. These records shall include:
(1) Identification data, including the person’s legal status;
(2) The person’s history, including but not limited to:
(A) Family data, educational background and employment record;
(B) Prior medical history, both physical and mental, including prior institutionalization;
(3) The person’s grievances, if any;
(4) An inventory of the person’s life skills;
(5) A record of each physical examination which describes the results of the examination;
(6) A copy of the individual habilitation plan; and any modifications thereto and an appropriate summary which will guide and assist the professional and staff employees in implementing the person’s program;
(7) The findings made in periodic reviews of the habilitation plan which findings shall include an analysis of the successes and failures of the habilitation program and shall direct whatever modifications are necessary;
(8) A medication history and status;
(9) A summary of each significant contact by a professional person with a person;
(10) A summary of the person’s response to his or her program, prepared and recorded at least monthly, by the professional person designated pursuant to § 7-1305.04(c) to supervise the person’s habilitation;
(11) A monthly summary of the extent and nature of the person’s work activities and the effect of such activity upon the person’s progress along the habilitation plan;
(12) A signed order by a professional person, as set forth in § 7-1305.10(b), for any physical restraints;
(13) A description of any extraordinary incident or accident in the facility involving the person, to be entered by a staff member noting personal knowledge of the incident or accident or other source of information, including any reports of investigations of person’s mistreatment;
(14) A summary of family visits and contacts;
(15) A summary of attendance and leaves from the facility; and
(16) A record of any seizures, illnesses, treatments thereof, and immunizations.
(b) Notwithstanding subsection (a) of this section, information contained in a person’s record may be used or disclosed for the purposes of and in accordance with Chapter 2B of this title [§ 7-241 et seq.].