Why Treatment Timing and Documentation Matter
In an injury claim, medical records do more than list diagnoses. They help connect the incident to your symptoms (timing), show what the provider observed (findings), and document what care was considered reasonable (treatment plan). When treatment is ongoing, the goal is to avoid confusion—especially about whether you are improving, whether new symptoms appeared, and whether you followed the plan or had a good reason you could not.
Common Scenarios and What They Often Mean
- ER-only care: If the records show only one early visit and no follow-up, insurers often argue the injury resolved quickly or was not serious. Ongoing care records (or a clear explanation for any delay) can help address that.
- Gaps in care: Gaps can raise questions about whether symptoms were truly persistent. If there is a gap, documentation that explains why (couldn’t get an appointment, referral delays, work constraints, etc.) can matter.
- “Done with treatment” / plan changes: If a note says you are “better,” “resolved,” or “at baseline,” that can be used to argue the claim ended—even if you later flare up. If your plan changes (for example, a referral for nerve testing or starting physical therapy), make sure the record clearly reflects the reason for the change.
Practical Documentation Tips (Non‑Medical)
- Send the right “core” records first: visit summaries/office notes, diagnostic test reports (not just the bill), and any written work restrictions or activity limits.
- Track objective vs. reported symptoms: Records that include measurable findings (exam findings, imaging results, documented spasms, strength/reflex findings, range-of-motion limits) can carry more weight than symptom descriptions alone. Both still matter—just keep them consistent.
- Keep a simple treatment timeline: appointment dates, what provider you saw (general type), what changed, and what the next step is (follow-up, referral, testing). This helps prevent misunderstandings when an adjuster reviews the file.
- Document referral efforts: If a referral stalls due to scheduling or communication issues, keep screenshots/notes of the dates you tried, who you contacted (no names needed), and what you were told. Ask the treating office to document the referral request and any follow-up attempts in the chart when possible.
- Avoid “medical conclusions” in your updates: Don’t label something as a specific condition unless a provider has documented it. Instead, report what you experience (for example, “arm pain with tingling”) and let the records speak for the diagnosis.
- Save billing and payment documents separately: Keep itemized bills and account statements, but understand that bills alone do not explain why treatment was needed. Pair bills with the matching visit note or test report when you can.
How This Applies
Apply to your situation: Because your arm pain may be nerve-related and you are pursuing a referral for testing, your most helpful updates are (1) the treating doctor’s visit note that documents your current symptoms and exam findings, (2) the written referral order and any test orders, and (3) the specialist’s report once testing occurs. Since the referral process previously stalled due to a communication issue, keep a dated log of your attempts and ask your treating provider’s office to note the referral status in the chart so the delay does not look like a treatment gap without explanation.
What the Statutes Say (Optional)
- N.C. Gen. Stat. § 1-52 (Civil actions—three years) – sets a three-year limitations period for many injury-related civil claims.
- N.C. Gen. Stat. § 90-411 (Medical record copy fees) – allows providers to charge regulated, per-page fees for copies of medical records.
Conclusion
When treatment is ongoing, focus on quality and consistency: visit notes, test reports, referral orders, and a clear timeline of what changed and what is planned next. Try to avoid unexplained gaps, and document referral delays so the record matches reality. If you are unsure what to send or how often to update, a licensed North Carolina personal injury attorney can help you organize the file and communicate in a way that supports the claim without creating avoidable problems.
