Understanding the Problem

If you are considering a North Carolina medical malpractice case, you are usually asking what you must provide so an attorney can review what the health care provider did, what harm followed, and whether the claim can be pursued on time. Since you already sent an attachment with a case summary, the next step is typically gathering the underlying medical records and a few key documents that let us confirm the timeline and identify the right providers and facilities.

Apply the Law

In North Carolina, a medical malpractice claim generally turns on whether a health care provider failed to meet the applicable standard of care and whether that failure caused injury and damages. Practically, that means we need records that show (1) what care was provided, (2) what should have been done under similar circumstances, (3) what changed in your condition, and (4) what losses resulted. North Carolina also has a special filing requirement for malpractice complaints that typically requires a qualified medical review before the lawsuit is filed, so collecting complete records early is often the difference between a review that can move forward and one that stalls.

Key Requirements

• Provider and facility identification: The full names (or best available identifiers) of the doctors, nurses, clinics, hospitals, and labs involved, plus where the care happened.
• Timeline of care: Dates of symptoms, visits, tests, procedures, discharge, follow-up, and when you first learned something might have gone wrong.
• Complete medical records: Records from before the event (baseline), the event itself (the key encounter), and after the event (complications and treatment).
• Key clinical documents: Operative reports, ER notes, nursing notes, medication administration records, lab results, radiology images/reports, pathology reports, and discharge instructions when applicable.
• Injury and outcome proof: Records showing the complication, new diagnosis, additional treatment, disability restrictions, and prognosis.
• Damages documentation: Medical bills, insurance explanation-of-benefits (EOBs), pharmacy receipts, and wage/work-impact records.
• Communications and paperwork: Consent forms, patient portal messages, complaint/grievance correspondence, and any letters you received about the care.

What the Statutes Say

• N.C. Gen. Stat. § 90-21.12 (Standard of health care) - Defines the standard-of-care framework used to judge whether malpractice occurred.
• N.C. Gen. Stat. § 8-53 (Health care provider-patient communications) - Addresses confidentiality of medical information and the need for patient authorization (or other legal basis) to obtain it.
• N.C. Gen. Stat. § 90-412 (Electronic medical records) - Confirms providers may keep records electronically and sets expectations for legibility and retrievability.
• N.C. Gen. Stat. § 131E-95 (Medical review committee confidentiality) - Explains why some internal hospital quality-review materials may not be available, even when other medical records are.

Analysis

Apply the Rule to the Facts: Because you have already provided a written case summary, the next step is usually verifying that summary against the actual chart: the visit notes, test results, orders, and follow-up care. We also need enough identifying information to request records from every provider involved, not just the main facility. Finally, we need documents showing what harm occurred and how it affected you, because a malpractice case requires more than proof that something “went wrong.”

Process & Timing

1. Who files: You (or your attorney with your permission). Where: Directly with each provider/facility’s medical records department (and sometimes imaging/lab vendors). What: A signed medical authorization and a targeted request for the complete chart, including billing and imaging. When: As soon as possible, because record collection and medical review can take time.
2. Review and gap-check: We compare your summary to the records to confirm dates, who made key decisions, what was documented, and whether any important pieces are missing (for example, nursing notes, medication administration records, or radiology images).
3. Medical review planning: If the records support further evaluation, we organize them for a qualified medical review (often requiring a complete, chronological set). This step is important in North Carolina because malpractice cases typically require a pre-filing review process before a complaint is filed.

Exceptions & Pitfalls

• Incomplete records requests: Asking only for “the ER record” or “the discharge summary” can miss the documents that matter most (like orders, nursing notes, medication administration records, consult notes, and imaging).
• Missing “before” and “after” records: In malpractice cases, baseline records and follow-up records often matter as much as the event itself because they help prove causation and damages.
• Confidential internal reviews: Patients often expect hospitals to turn over internal quality-review or peer-review materials; North Carolina law protects many of those materials from disclosure, even when the underlying medical chart is available.
• Provider identity confusion: Large facilities may involve multiple separate entities (hospital, physician group, radiology group, lab). If we do not identify them correctly, record requests and later case evaluation can be delayed.
• Timeline uncertainty: If you are not sure when symptoms started, when you were told key information, or when follow-up occurred, it can be harder to evaluate both liability and deadlines. Your best estimate still helps us start the investigation.

If you want more general background on handling medical records in injury cases, you may find these helpful: what medical records to keep while still in treatment and how long it can take to get medical bills and records.

Conclusion

To evaluate a North Carolina medical malpractice claim, an attorney typically needs (1) a clear timeline, (2) the identities of all providers and facilities involved, (3) complete medical records (before, during, and after the event), and (4) documents showing injury and losses like bills and work-impact records. Because North Carolina malpractice cases usually require a qualified medical review before filing suit, the most important next step is to sign medical authorizations so the complete chart can be requested right away.