How do I obtain a copy of my medical records?
Submit an authorization request form directly to the Health Information Services (HIS) department in person or by mail. Please bring identification with you to the hospital when you submit your authorization form. If you are submitting the request by mail, please send a copy of your picture identification along with your request. (Examples: drivers license, identification card, student identification, passport and military identification card).
Is there a fee to obtain a copy of my medical record?
No fee will be charged for records copied at the request of a health care provider (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. There is a $10 retrieval fee and a charge of $0.50 per page (South Carolina State Statute, Section 44-7-325).
In certain cases, a copy service (HealthPort) fulfills your request. There is a $15.00 retrieval fee. A fee of no more than $0.65 per page up to 30 pages and $0.50 per page thereafter will be billed plus taxes and postage (South Carolina State Statute, Section 44- 115-80).
Payment must be made before records are sent. Records requests are usually processed within seven to 10 business days.
What information is needed on a valid authorization release form?
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:
- Patient 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 (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.
- An expiration date.
- Signature of patient or patient’s representative.
What is included on a medical record and what should I request?
The following provides a brief summary of the various parts of a medical record that may help to identify information to request:
- Discharge Summary: A clinical report prepared by a physician or other health professional at the conclusion of a hospital stay or series of treatments. The report outlines the patient's chief complaint, the diagnostic findings, the therapy administered, medications prescribed and the patient's response to it and recommendations on discharge.
- History and Physical: A medical history includes the present chief complaint, history of the present illness, past medical history, personal history, family history and a review of systems.
- Consultation Report: A report on the patient's illness or condition from a practitioner other than the attending physician.
- 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 and pharmacists, among others, can also be included. These are more specifically referred to as “interdisciplinary progress notes.”
- Physician Orders: This includes both written and verbal orders from physicians, nursing staff, the patient and other caregivers.
- Nursing Notes: This is a 24-hour account of a patient’s well being as determined by the patient’s nurse.
- 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, please contact the Radiology File Room at (843) 522-5132. If you would like the requested information on CD, please contact Health Information Services at (843) 522-5993.
- Laboratory Results: Analysis of blood or urine and surgical pathology reports or biopsies, which document tissue examinations, among others.
- Medication List: This is a daily account of all medications and dosages administered to a patient during his or her stay.
When should I expect to receive my medical records?
According to South Carolina Statute, Section 42-15-95, Beaufort Memorial Hospital shall comply with a request for medical records no later than 30 days after the request has been received. Our goal is to complete requests within 7 to 14 days of receipt. We understand that at times extenuating circumstances do not allow for completion within a 30-day timeframe. We make every effort to accommodate 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, the record must be requested by the court appointed "personal representative" presenting a raised seal original certificate of appointment issued by the Probate Court identifying the requester as the executor or executrix of the patient's estate.
- 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 may 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.