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Following are frequently asked questions about obtaining medical records from the Medical University of South Carolina.

• Name and date of birth or social security number
• Statement of who is authorized to release records and who is authorized to receive records
• Purpose of Disclosure
• Type of information to be disclosed
• Psychiatric records or infectious diseases (i.e. HIV, Hepatitis C, TB, etc.) must be clearly marked or checked before they will be released
• Statement acknowledging the patient's right to revoke or cancel authorization
• Statement indicating the patient’s right to refuse the release of information
• Statement that information disclosed pursuant to the authorization may be subject to re-disclosure and is no longer protected under this authorization
• Statement that will not condition treatment on patient providing authorization
• An expiration date
• Signature of patient or patient’s representative 

Is there a fee to obtain my records?
No fee will be charged for records copied at the request of a health care provider (i.e. physician, nurse practitioner, nurse, etc.) or for records sent to a health care provider at the request of the patient for the purpose of continuing care.  However, there is a fee charged for the search and duplication of medical records for personal reasons, attorney’s requests, and insurance requests.  As outlined in SC state statute, Section 44-7-130, a fee of no more than $0.65 per page up to 30 pages and $0.50 per page thereafter will be billed.  In certain cases, a clerical fee of $15.00 will be administered.  Requestors will be sent a prepayment invoice upon determination of total cost.

What is included within a medical record and what should I request?
The following provides a brief summary of the various parts of a medical record which may help to identify information to request:

1. Discharge Summary: A summary of an inpatient stay.  This report identifies the reason for the admission and narrates the patient’s course during the stay.  Diagnoses, operations performed, medications prescribed, and condition at discharge are all items of inclusion. 
2. History & Physical: A medical history which includes the present chief complaint, history of the present illness, past medical history, personal history, family history, and a review of systems.
3. Consultation Report: A report outlining the opinion about the illness or condition from a practitioner other than the attending physician. 
4. Physician Progress Note: A specific, daily account of the patient’s illness and response to treatment as noted by the physician.  Notes from dieticians, physical therapists, or pharmacists, among others can also be included, which are more specifically referred to as “interdisciplinary progress notes.”
5. Physician Orders: This reports both written and verbal orders from physicians to their nursing staff and other caregivers.
6. Nursing Notes: This is a 24-hour account of a patient’s wellbeing as checked by the patient’s nurse.
7. Radiology Report: This is a dictated report summarizing the findings of images or scans as viewed by the radiologist.  If you would like the actual film on CD please contact the Radiology File Room at 792-7439.
8. Laboratory Results: Analysis of blood or urine and surgical pathology reports or biopsies which document tissue examinations, among others.
9. Medication List: This is a daily account of all medications and dosages administered to a patient during their stay.      

When should I expect to receive my medical records?
According to South Carolina Statute, Section 42-15-95, MUSC shall comply with a request for medical records no later than 45 days after the request has been received.  The goal at MUSC is to complete requests within 7 to 30 days of receipt.  We understand that at times extenuating circumstances do not allow for 45 days; therefore, we make every effort to accommodate to satisfy our patients’ needs.

Who can legally sign for medical records?

• The Patient and/or anyone who is named as a decision maker or attorney-in-fact under a healthcare power of attorney signed by the patient.
• If the patient is deceased, a certificate of appointment issued by the Probate Court identifying the requestor as the executor or executrix of the patient’s estate. A death certificate may also be provided which lists the requestor as the next of kin.
• If the patient is under the age of 16, the patient’s parent may sign.
• If the patient is 16 years of age or older, the parent can sign if the parent authorized the treatment which is recorded.  If the patient is 16 years of age or older and authorized their own treatment, then the patient must authorize the release of information regarding the treatment.
• If the patient is incapacitated with no healthcare power of attorney, the next of kin as stated in the Adult Healthcare Consent Act, S.C. Code of Laws Section 44-66-20, may authorize the release of information.

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