Montana Code Annotated
Part 1. Treatment
53-20-161. Maintenance of records

53-20-161. Maintenance of records. (1) Complete records for each resident must be maintained and must be readily available to persons who are directly involved with the particular resident and to the mental disabilities board of visitors. All information contained in a resident's records must be considered privileged and confidential. The parents or guardian, the responsible person appointed by the court, and any person properly authorized in writing by the resident, if the resident is capable of giving informed consent, or by the resident's parents or guardian or the responsible person must be permitted access to the resident's records. Information may not be released from the records of a resident or former resident of the residential facility unless the release of the information has been properly authorized in writing by:
(a) the court;
(b) the resident or former resident if the resident or former resident is over the age of majority and is capable of giving informed consent;
(c) the parents or guardian in charge of a resident under the age of 12;
(d) the parents or guardian in charge of a resident over the age of 12 but under the age of majority and the resident if the resident is capable of giving informed consent;
(e) the guardian of a resident over the age of majority who is incapable of giving informed consent; or
(f) a residential facility, through an individual designated by the department of public health and human services by rule, when the facility is the custodian of a resident:
(i) over the age of majority who is incapable of giving informed consent and for whom no legal guardian has been appointed;
(ii) under the age of majority for whom there is no parent or legal guardian; or
(iii) of the facility whenever release is required by federal or state law or department rules.
(2) Information may not be released by a residential facility under subsection (1)(f) less than 15 days after sending notice of the proposed release of information to the resident, the resident's parents or guardian, the attorney who most recently represented the resident, if any, the responsible person appointed by the court, if any, the resident's advocate, if any, and the court that ordered the admission. If any of the parties notified under this subsection objects to the release of information, the party may petition the court for a hearing to determine whether the release of information should be allowed. Information may not be released pursuant to subsection (1)(f) unless it is released to further a legitimate need of the resident or to accomplish a legitimate purpose of the facility that is not inconsistent with the needs and rights of the resident. Information may not be released pursuant to subsection (1)(f) except in accordance with written policies consistent with the requirements of this part adopted by the facility. Persons receiving notice of a proposed release of information must also receive a copy of the written policy of the facility governing release of information.
(3) These records must include:
(a) identification data, including the resident's legal status;
(b) the resident's history, including but not limited to:
(i) family data, educational background, and employment record; and
(ii) prior medical history, both physical and mental, including prior institutionalization;
(c) the resident's grievances, if any;
(d) an inventory of the resident's life skills, including mode of communication;
(e) a record of each physical examination that describes the results of the examination;
(f) a copy of the individual habilitation plan and any modifications to the plan and an appropriate summary to guide and assist the resident care workers in implementing the resident's habilitation plan;
(g) the findings made in monthly reviews of the habilitation plan, including an analysis of the successes and failures of the habilitation program and whatever modifications are necessary;
(h) a copy of the postinstitutionalization plan that includes a statement of services needed in the community and any modifications to the postinstitutionalization plan and a summary of the steps that have been taken to implement that plan;
(i) a medication history and status;
(j) a summary of each significant contact by a qualified intellectual disability professional with a resident;
(k) a summary of the resident's response to the resident's habilitation plan, prepared by a qualified intellectual disability professional involved in the resident's habilitation and recorded at least monthly. Wherever possible, the response must be scientifically documented.
(l) a monthly summary of the extent and nature of the resident's work activities and the effect of the activity on the resident's progress in the habilitation plan;
(m) a signed order by a qualified intellectual disability professional or physician for any physical restraints;
(n) a description of any extraordinary incident or accident in the facility involving the resident, 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 the resident's mistreatment;
(o) a summary of family visits and contacts;
(p) a summary of attendance and leaves from the facility; and
(q) a record of any seizures; illnesses; injuries; treatments of seizures, illnesses, and injuries; and immunizations.
History: En. 38-1223 by Sec. 23, Ch. 468, L. 1975; R.C.M. 1947, 38-1223; amd. Sec. 10, Ch. 485, L. 1979; amd. Sec. 21, Ch. 381, L. 1991; amd. Sec. 19, Ch. 255, L. 1995; amd. Sec. 473, Ch. 546, L. 1995; amd. Sec. 17, Ch. 68, L. 2013; amd. Sec. 13, Ch. 444, L. 2015.

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