Maintenance of records; information considered privileged and confidential; access; contents.

Complete records for each individual shall be maintained and shall be readily available to professional persons and to the staff workers who are directly involved with the particular individual and to the Department on Disability Services without divulging the identity of the individual. All information contained in an individual’s records shall be considered privileged and confidential. The individual’s parent or guardian who petitioned for the commitment, the individual’s counsel, the individual’s advocate for a person with an intellectual disability and any person properly authorized in writing by the individual, if such individual is capable of giving such authorization, shall be permitted access to the individual’s records. These records shall include: Identification data, including the individual’s legal status; The individual’s history, including but not limited to: Family data, educational background and employment record; Prior medical history, both physical and mental, including prior institutionalization; The individual’s grievances, if any; An inventory of the individual’s life skills; A record of each physical examination which describes the results of the examination; 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 individual’s program; 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; A medication history and status; A summary of each significant contact by a professional person with an individual; A summary of the individual’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 individual’s habilitation; A monthly summary of the extent and nature of the individual’s work activities and the effect of such activity upon the individual’s progress along the habilitation plan; A signed order by a professional person, as set forth in § 7-1305.10(b), for any physical restraints; A description of any extraordinary incident or accident in the facility involving the individual, 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 individual’s mistreatment; A summary of family visits and contacts; A summary of attendance and leaves from the facility; and A record of any seizures, illnesses, treatments thereof, and immunizations. Notwithstanding subsection (a) of this section, information contained in an individual’s record may be used or disclosed for the purposes of and in accordance with Chapter 2A of this title [§ 7-251 et seq.].