Short Answer

In North Carolina, you should keep a complete, organized set of records that shows (1) what care you received, (2) what it cost, and (3) how your symptoms and restrictions changed over time. That usually means visit notes, diagnostic results, prescriptions, therapy records, work-status notes, and every bill and payment record. While your providers can produce records later, keeping your own copies during treatment helps prevent gaps and makes it easier to prove your medical expenses and the timeline of your recovery.

Understanding the Problem

If you are still treating in North Carolina and you are going to appointments twice per week, what medical records must you keep now so you can later support your injury claim while treatment is ongoing?

Apply the Law

To support an injury claim, your documentation needs to connect your medical care to your reported symptoms and show the charges and payments tied to that care. In North Carolina civil cases, medical bills and medical records can be used as evidence, but they work best when they are complete and consistent across providers. Also, North Carolina law gives certain medical providers a statutory lien on injury recoveries for treatment-related charges, which makes it important to keep itemized statements and related records organized while you are still treating.

Key Requirements

• Proof of treatment: Keep records that show each appointment happened (date, provider, and what was done).
• Proof of diagnosis and findings: Keep imaging and test results (and the written reports) that document objective findings and clinical impressions.
• Proof of symptoms and functional limits: Keep records that show what you reported (like headaches) and what restrictions the provider gave you.
• Proof of charges: Keep itemized bills and statements showing what was charged for each service.
• Proof of payments and balances: Keep EOBs from health insurance, receipts, and account ledgers showing what was paid and what is still owed.
• Consistency over time: Keep records in date order so the timeline of improvement (or flare-ups) is clear.

What the Statutes Say

• N.C. Gen. Stat. § 8-58.1 (Medical charges evidence) - Allows an injured person to testify about amounts paid or required to be paid for medical-related charges if records accompany the testimony, and creates certain rebuttable presumptions about reasonableness.
• N.C. Gen. Stat. § 8-44.1 (Hospital medical records) - Addresses how hospital medical records can be received as evidence if otherwise admissible, including through the custodian process.
• N.C. Gen. Stat. § 44-49 (Medical provider lien on personal injury recoveries) - Creates a lien in favor of certain providers for treatment-related charges connected to the injury recovery and includes requirements tied to itemized statements/notice.
• N.C. Gen. Stat. § 44-50 (Duty to retain funds for lien claims; cap) - Explains how lien claims attach to settlement funds and sets limits and handling requirements before disbursement.

Analysis

Apply the Rule to the Facts: Because you are still treating twice per week and still reporting symptoms like headaches, the most helpful records are the ones that show a continuous timeline: each visit, what you told the provider, what the provider found, and what the plan was going forward. You also want every bill and payment record tied to those visits so your medical expense claim is supported by documents, not memory. Since your provider is noting some improvement but treatment is ongoing, keeping progress notes and work-status/restriction notes helps show how your condition is changing over time.

Process & Timing

1. Who files: You (or your attorney) requests records from each provider. Where: Each provider’s medical records department or patient portal in North Carolina. What: Ask for the complete chart (visit notes), diagnostic reports, and billing ledger/itemized statements; also request insurance EOBs from your health insurer. When: Start now and update your file at least monthly while you are treating.
2. Keep a running “treatment packet”: Save documents in date order and separate them by provider (urgent care, primary care, specialists, therapy, imaging, pharmacy). If you switch providers midstream, keep the referral and transfer paperwork so the timeline stays clear.
3. Preserve the “billing trail”: For each provider, keep (a) the itemized bill, (b) the insurance EOB (if any), and (c) proof of what you paid out of pocket. This makes it easier to show what was charged versus what was actually paid or still owed.

Exceptions & Pitfalls

• Gaps in care: Long breaks in treatment without a clear reason can create arguments that your symptoms resolved or that something else caused them. If you have to miss visits, keep the rescheduling messages and the provider’s instructions.
• Missing “objective” records: People often save bills but not the actual clinical notes and diagnostic reports. Bills show cost; notes and reports show what was treated and why.
• Only keeping portal screenshots: Portals are helpful, but they can change. Download PDFs of visit summaries, imaging reports, and account ledgers and store them in a separate folder.
• Not tracking prescriptions and over-the-counter recommendations: Keep pharmacy printouts, medication lists, and written instructions. These help show symptom management and side effects.
• Confusing charges with payments: In real cases, the “amount billed” and the “amount paid/owed” can differ. Keep EOBs and receipts so the numbers can be explained cleanly.
• Lien surprises: Some providers may assert lien rights for treatment charges connected to the injury recovery. Keep any lien notices and itemized statements so you can address them before settlement funds are distributed.

Conclusion

While you are still in treatment in North Carolina, keep records that prove your care, your symptoms and restrictions, and your medical charges and payments over time. Focus on complete visit notes, diagnostic reports, therapy records, prescriptions, and every itemized bill and insurance EOB. A practical next step is to request a complete copy of your chart and an itemized billing ledger from each treating provider now, then update your file monthly while treatment continues.

Talk to a Personal Injury Attorney

If you're dealing with an injury claim while treatment is still ongoing, an attorney can help you identify the records that matter most, spot gaps before they become problems, and organize bills, EOBs, and lien issues so your claim is supported by clear documentation. Call (800) 333-8405 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.