What medical records should I keep to support a slip-and-fall injury claim, especially if I might need more testing later?
What medical records should I keep to support a slip-and-fall injury claim, especially if I might need more testing later? - North Carolina
Short Answer
In North Carolina, keep every record that shows (1) what you complained of, (2) what providers found on exam and imaging, (3) what treatment was recommended, and (4) what it cost. That includes urgent care notes, imaging reports (and the actual images if you can get them), prescriptions, follow-up referrals, and all billing/insurance paperwork. If you may need more testing later, also keep documents that show your symptoms continued and that your provider recommended additional evaluation—because gaps and missing records can make it harder to connect later testing to the fall.
Understanding the Problem
If you were hurt in North Carolina and you want to bring a slip-and-fall claim, the key question is: what medical records should you keep to prove the fall caused your injuries and to support future testing if your symptoms don’t resolve? Here, one important fact is that you went to urgent care for evaluation and imaging after landing on a knee with an old injury.
Apply the Law
In a North Carolina slip-and-fall claim, medical records matter because they help prove causation (the fall caused or worsened an injury) and damages (the medical care you reasonably needed). The most useful records are the ones created close in time to the fall and the ones that show a consistent medical story over time—especially when the injured body part had a prior condition. If a lawsuit becomes necessary, the filing deadline for most personal injury claims is generally three years, so you should preserve records early and keep them organized while treatment is ongoing.
Key Requirements
Complete treatment timeline: Keep records from the first visit (urgent care/ER) through every follow-up, including any gaps and the reason for them.
Objective findings: Save imaging reports (X-ray/MRI/CT/ultrasound), radiology impressions, and exam findings that document swelling, instability, reduced range of motion, or other measurable issues.
Provider recommendations: Keep referrals, work restrictions, physical therapy plans, and “return precautions” showing what your provider told you to do next and why more testing might be needed.
Medication and devices: Keep prescriptions, medication instructions, and records for braces, crutches, or other durable medical equipment.
Bills and payment records: Keep itemized bills, receipts, and insurance Explanation of Benefits (EOBs) to show charges, adjustments, and out-of-pocket costs.
Prior records for the same body part (when relevant): If you had an old knee injury, keep prior baseline records so your providers (and later, an insurer) can see what changed after the fall.
Apply the Rule to the Facts: Because you went to urgent care and had imaging after the fall, your urgent care chart and radiology report are the foundation of your medical proof. Since you landed on a knee with an old injury, records that separate “what was already going on” from “what changed after the fall” become especially important. If you later need more testing (like an MRI), the best support is a clear paper trail showing ongoing symptoms, follow-up complaints, and a provider’s documented reason for ordering additional studies.
Process & Timing
Who requests records: You (or your attorney with a signed authorization). Where: Each provider’s medical records department (urgent care, imaging center, orthopedist, physical therapy). What: Request the full chart (visit notes, triage/vitals, discharge instructions), radiology report, and a digital copy of images (often on a disc or secure download). When: Start now and keep requesting updated records after each new visit.
Keep a running “records packet”: Save PDFs/screenshots of after-visit summaries, referral orders, and portal messages where a provider documents persistent symptoms or recommends additional testing. This helps show why later testing was medically connected to the fall rather than a new issue.
Preserve billing and insurance documents: Keep itemized bills and EOBs as they arrive. If you later need an MRI, injections, or surgery, those future bills and EOBs become part of the same organized file.
Exceptions & Pitfalls
Gaps in treatment: Long breaks without documented medical follow-up can make it easier for an insurer to argue your later symptoms (and later testing) are unrelated. If you can’t treat for a period, keep documentation showing why (for example, scheduling delays or referral wait times).
Only keeping summaries: After-visit summaries are helpful, but they are not the whole chart. The full record often contains the detailed exam, differential diagnosis, and clinical reasoning that supports why more testing was appropriate.
Missing imaging materials: The radiology report is important, but the actual images can matter later if another doctor reviews them or compares them to new studies.
Not documenting the “old injury” baseline: When a knee had prior problems, insurers often argue the fall did not cause the condition. Prior records can help show what was stable before and what worsened after.
Mixing up billing paperwork: Keep provider bills separate from insurance EOBs. An EOB is not a bill, but it can prove what was charged, what insurance paid, and what you may still owe.
Informal notes replacing medical documentation: A personal symptom journal can help you remember dates, but it does not replace provider records. Use it to support consistent reporting to your doctors.
Conclusion
To support a North Carolina slip-and-fall injury claim—especially when more testing may be needed later—keep complete medical records that show your symptoms, exam findings, imaging results, treatment plan, and costs from start to finish. This is even more important when the injured area had a prior condition, like an old knee injury, because the records help show what changed after the fall. Your next step is to request and save the full urgent care chart and imaging report now, and keep collecting updated records as you follow up, keeping the three-year filing deadline in mind.
Talk to a Personal Injury Attorney
If you're dealing with a slip-and-fall injury and trying to protect your claim while you’re still treating (or may need more testing later), our firm has experienced attorneys who can help you understand what documentation matters and what timelines to watch. Reach out today. Call [CONTACT NUMBER].
Disclaimer: This article provides general information about North Carolina law based on the single question stated above. It is not legal advice for your specific situation and does not create an attorney-client relationship. Laws, procedures, and local practice can change and may vary by county. If you have a deadline, act promptly and speak with a licensed North Carolina attorney.
