CHAPTER 5. RECORDS

Art. 1416. Facility records; confidentiality; disclosure; destruction

A. Complete records for each minor shall be maintained and all information contained in a minor patient's records shall be considered privileged and confidential and shall not be disclosed except as provided herein.

B. A minor patient's record shall be readily available to both the qualified professionals and the residential care workers who are directly involved with the minor.

C. The parent or tutor of the minor shall be permitted access to his records. These records shall include:

(1) Identification data, including the minor's legal status.

(2) The minor'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 minor patient's grievances if any.

(4) An inventory of the minor's life skills.

(5) A record of each physical examination describing the results of the examination.

(6) A copy of the minor's individual plan and any modifications thereto and an appropriate summary to guide and assist resident care workers in implementing the minor's program.

(7) The findings made in periodic reviews of the plan, including an analysis of the successes and failures of the minor patient's program and recommendations for any modifications deemed necessary.

(8) A copy of the post-institutionalization plan and any modifications thereto, and a summary of the steps that have been taken to implement that plan.

(9) History and present status with respect to medication.

(10) A summary of each significant contact with the minor by a qualified professional.

(11) A summary of the minor patient's response to his program, prepared by a qualified professional involved in his treatment and recorded at least monthly. Such response wherever possible, shall be scientifically documented.

(12) A signed order by a qualified professional for any physical restraints or seclusion, and documentation of the clinical justification for the use of restraints, seclusion, and placement as required by Articles 1409(D) and (E).

(13) A description of any extraordinary incident or accident in the institution involving the minor, 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 mistreatment of the child, as required by Article 1410.

(14) A summary of family visits and contacts.

(15) A summary of attendance and leaves from the institution.

(16) A record of any seizures, illnesses, treatments thereof, and immunizations.

D. Any attorney representing a minor with mental illness or a respondent as defined herein shall have ready access to view and copy all mental health and developmental disability records pertaining to his client unless the client objects. The attorney shall return all copies of his client's medical record to the treatment facility upon completion of their use. If the patient or respondent later retains a private attorney to represent him, the MHAS shall destroy all copies of records pertaining to his case.

E. Any respondent or minor with a mental disability shall have the right to demand that the records in the possession of his attorney regarding his mental condition be destroyed or returned to the treatment facility and he shall have the right to assurance by the director that such records have been so destroyed by the MHAS attorney.

Acts 1991, No. 235, §14, eff. Jan. 1, 1992; Acts 1995, No. 1287, §2, eff. June 29, 1995; Acts 2014, No. 811, §33, eff. June 23, 2014.