Patients & Visitors

Patients & Visitors

Frequently Asked Questions

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

Authorization form sample

What is a Valid Authorization?

The Health Insurance Portability & Accountability Act (HIPAA) sets the standard for a valid authorization to release information.  The following elements must be included for a HIPAA-compliant authorization:

  • 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 and must be physician approved except for payment, treatment, or operations
  • 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.
  • The first 20 pages are free and a charge of $0.45 per page in excess of 20 pages.    
  • Third party requests  (attorney’s , insurance, etc. ) will be charged  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.
  • Radiology imaging copy charges:
    • $15.00 for patients
    • $50.00 for third party requestors
    • ($5.00 each additional copy)
    • *Plus tax and postage fess

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 792-3881.
  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.
  10. 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?

  • Healthcare Power of Attorney:
    • 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. 
  • Durable Power of Attorney:
    • If there is a durable power of attorney, a pre-approval is required by the Release of Information staff.
  • If the patient is deceased, the record must be requested by the court appointed "personal representative" presenting a raised seal original certificate of appointment issued by the Probate Court.
  • If the patient is under the age of 16, the patient’s parent may sign.
  • If you have other special circumstances, please contact the Release of Information Supervisor for assistance at 843-792-3881.
 
 
 

© Medical University of South Carolina | 171 Ashley Avenue, Charleston, SC 29425