What medical records or documents should I provide to show my treatment progress?
What medical records or documents should I provide to show my treatment progress? - North Carolina
Short Answer
In a North Carolina personal injury claim, you should provide documents that show (1) what treatment you received, (2) when you received it, (3) what your providers said about your diagnosis, restrictions, and prognosis, and (4) what the treatment cost. In practice, that usually means visit notes, imaging reports, therapy/chiropractic notes, prescriptions, work-status notes, and itemized bills. If your treatment is still ongoing, provide the most recent records and your next scheduled appointment information so your lawyer can track progress and avoid gaps.
Understanding the Problem
If you have an ongoing North Carolina personal injury claim and your lawyer is asking whether your medical treatment is still ongoing or completed, the key question is: what medical records and related documents can you provide to show your treatment progress, including where you are in the treatment plan right now?
Apply the Law
North Carolina personal injury cases often require proof of your injuries and how they changed over time. Medical records are also generally confidential, so they are typically shared through your written authorization, a subpoena, or (in some situations) a court order. If a lawsuit is filed, medical records can also be obtained and used through the civil discovery process, and hospital records have specific rules that can make them easier to admit into evidence when properly obtained from the custodian of records.
Key Requirements
Proof of treatment timeline: Records should show the dates you were seen, what complaints you reported, and what care you received at each visit.
Diagnosis and objective findings: Include imaging and test reports (like X-ray, MRI, CT, EMG) and provider assessments that connect symptoms to findings.
Plan of care and progress: Notes should show what your provider recommended, whether you improved, and whether treatment is continuing or has reached maximum improvement/discharge.
Work and activity restrictions: Provide work notes, restrictions, return-to-work releases, and any disability or FMLA paperwork your provider completed.
Medication and referrals: Include prescription lists, medication changes, and referrals to specialists, therapy, pain management, or additional testing.
Charges and payments: Itemized bills, ledgers, and EOBs (explanations of benefits) help document medical expenses and what remains owed.
Apply the Rule to the Facts: Because your claim appears ongoing and you are still receiving treatment, the most helpful documents are the most recent provider notes and therapy records showing what has changed since your last update, plus any upcoming appointments that confirm treatment is continuing. Your lawyer also needs documents that show the full treatment timeline (from first visit to the present), objective testing (imaging and results), and the financial side (itemized bills/EOBs) so the claim can be evaluated and updated accurately.
Process & Timing
Who provides: You (the client) and, if needed, your medical providers. Where: Usually directly to your attorney’s office in North Carolina (secure upload/email/mail as instructed). What: (a) a signed medical authorization your attorney provides, and (b) copies you already have—discharge instructions, work notes, imaging reports, PT/chiro progress notes, prescriptions, bills, and EOBs. When: As soon as possible after each new visit or at least monthly while treatment is ongoing.
Next step: Your attorney typically requests complete records and billing from each provider and then updates the claim file as new treatment occurs. If there is a gap in care, your attorney may ask you to explain it and to confirm your next appointment date.
Final step: When treatment ends, provide your discharge paperwork or a final note stating you were released from care (or that no further treatment is planned), along with final bills/ledgers so the file can be updated for settlement negotiations or litigation.
Exceptions & Pitfalls
Gaps in treatment: Long breaks without documented reasons can be used to argue you were improving, not hurt, or not following medical advice. If a gap happened, share the reason (for example, scheduling delays or insurance issues) so it can be documented appropriately.
Only sending bills (or only sending notes): Bills show cost, but not medical findings; notes show findings, but not cost. Your attorney usually needs both.
Missing imaging “reports”: A photo of a disk or a screenshot is not the same as the radiology report and impression. Send the written report if you have it.
Incomplete provider list: If you forget a clinic (urgent care, PT, chiropractor, specialist), your attorney may miss records that the other side later finds, which can create credibility issues.
Privacy and scope: Medical records are confidential under North Carolina law, but injury claims can still require disclosure of relevant records. Talk with your attorney before signing any broad authorization you do not understand.
Conclusion
To show treatment progress in a North Carolina personal injury claim, provide records that document your visit dates, diagnoses, testing results, treatment plan, restrictions, and charges—especially your most recent notes if care is still ongoing. Medical information is generally confidential, so your attorney will usually use your written authorization to gather complete records and billing. Next step: send your attorney your latest visit note (or discharge note if finished) and your next appointment date as soon as you can.
Talk to a Personal Injury Attorney
If you're dealing with an injury claim and ongoing medical treatment, a personal injury attorney can help you understand what records matter, how to document progress, and how timing and gaps in care can affect the claim. Reach out today.
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.
