Short Answer

In North Carolina, the strongest injury claims are supported by records that prove (1) what happened medically, (2) that the treatment connects to the crash, and (3) what it cost you. After a head injury with EMS transport, an ER visit, imaging, stitches, and therapy, you should gather the EMS report, full hospital/ER chart, imaging reports (and images if available), follow-up and therapy records, and every bill and payment record (including insurance explanations of benefits). Keep a simple symptom and work-impact log so your records match your day-to-day reality.

Understanding the Problem

If you were hurt in a North Carolina car wreck and you were taken by EMS to the emergency room for a head injury with loss of consciousness, what medical records and documents should you gather now so you can show the other side what care you received and why you needed it?

Apply the Law

In a North Carolina injury claim, the key medical paperwork does two jobs: it documents your diagnosis and treatment (so the insurer or jury can see what happened), and it supports damages (so the financial impact is clear). Practically, you want records that show the timeline from the crash to EMS/ER care, the objective findings (like imaging and exam notes), the treatment plan and follow-up, and the amounts paid or still owed. If medical charges become an issue in a civil case, North Carolina law allows an injured person to testify about amounts paid or required to be paid, as long as the charge records accompany that testimony.

Key Requirements

• Complete treatment timeline: Records should cover the full arc from EMS pickup to ER/hospital stay to follow-ups and therapy, with dates that line up.
• Objective head-injury documentation: ER physician notes, nursing notes, neuro checks, imaging reports, and discharge instructions often carry the most weight early in a claim.
• Causation support: Notes that describe the crash history, loss of consciousness, symptoms, and why the provider believed the care was needed help connect treatment to the wreck.
• Itemized billing and payment proof: Collect itemized statements, provider bills, and proof of what was paid versus what is still owed (including insurance EOBs).
• Ongoing care documentation: Physical therapy evaluations, progress notes, and attendance records help show persistence of symptoms and functional limits.
• Out-of-pocket and practical impact: Receipts and logs for prescriptions, medical supplies, mileage, and missed work help fill gaps that medical charts do not capture.

What the Statutes Say

• N.C. Gen. Stat. § 8-58.1 (Medical charges evidence) - Allows testimony about amounts paid or required to be paid for medical charges when supported by the charge records, and creates certain rebuttable presumptions about reasonableness.
• N.C. Gen. Stat. § 44-49 (Medical provider liens) - Creates a lien right for certain medical/ambulance providers on personal injury recoveries and ties lien validity to providing itemized statements/records and notice to the attorney.
• N.C. Gen. Stat. § 108A-57 (Medicaid subrogation) - Gives the State subrogation rights for Medicaid payments and sets notice and timing rules after settlement/judgment proceeds are received.

Analysis

Apply the Rule to the Facts: Because you report a head laceration/bruise with loss of consciousness and EMS transport to the ER, the most important records are the EMS run sheet and the ER/hospital chart showing your initial condition, exam findings, imaging/tests, and discharge plan. Since you had stitches and a short hospital stay, you will also want procedure notes, nursing notes, and discharge instructions that document wound care and follow-up. Because you are now in physical therapy, your PT evaluation and progress notes help show ongoing symptoms and functional limits. Finally, because insurance did not cover everything, you should gather itemized bills, EOBs, and payment records to show what is still owed and what has already been paid.

Process & Timing

1. Who files: You (or your attorney) requests records from each provider. Where: Each provider’s medical records department (EMS agency, hospital, radiology group, therapy clinic, and any follow-up providers) in North Carolina. What: Ask for the “complete medical record/chart” and “itemized billing,” plus imaging reports and (if available) the actual images on disc/portal download. When: Start as soon as possible; it is easier to gather records while treatment is ongoing and providers still have easy access to the full chart.
2. Organize by provider and date: Keep separate folders for (a) records/clinical notes and (b) billing/payment documents. Match each bill to the corresponding date of service in the chart.
3. Update as treatment continues: Request updated PT notes and any new follow-up records every few weeks or at major milestones (new diagnosis, discharge from therapy, referral to a specialist, or new imaging).

Exceptions & Pitfalls

• Only requesting “a summary” instead of the full chart: For head injuries, the details matter (triage notes, neuro checks, radiology reports, discharge instructions). Ask for the complete ER/hospital record, not just a discharge summary.
• Forgetting imaging documentation: Get the written radiology report and, when possible, the actual images. The report often contains the key findings and impressions that insurers focus on.
• Mixing up bills vs. EOBs: A bill shows what the provider charged; an EOB shows what insurance processed and what you may still owe. You typically need both to clearly prove damages.
• Gaps in treatment: Long gaps can make the insurer argue your symptoms were not serious or were caused by something else. If you have a gap for a real reason (couldn’t get an appointment, transportation issues, symptoms changed), document it.
• Not tracking out-of-pocket costs: Mileage to appointments, prescriptions, wound-care supplies, and copays add up, but they rarely appear in the medical chart unless you keep receipts.
• Liens and subrogation surprises: Some providers and payors may claim reimbursement rights from a settlement. Keep every notice you receive and do not assume “insurance paid it, so it’s done.”

Conclusion

To support a North Carolina injury claim after a head injury car wreck, gather records that prove your diagnosis and treatment timeline (EMS report, complete ER/hospital chart, imaging reports, procedure notes, discharge instructions, and PT records) and documents that prove your financial losses (itemized bills, EOBs, and payment balances). These records help show what care you needed, why you needed it, and what it cost. Next step: request your complete EMS and hospital records and itemized billing as soon as possible.

Talk to a Personal Injury Attorney

If you're dealing with a head injury claim after a car wreck and you’re trying to gather the right medical records and billing documents, our firm has experienced attorneys who can help you understand what to request, how to organize it, and what timelines may matter. Reach out today at 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.