A New Jersey Appellate Division panel has ruled that a hospital is obligated to provide a narrative road map specifying the location in the patient's chart where an adverse medical incident is documented.

The appeals court said plaintiff Heather Trella is entitled to discovery of any adverse incidents, or unintended injuries or illnesses that may have been preventable, that should have been documented in her medical records. The appeals court also said the trial court did not abuse its discretion by ordering Newton Medical Center to produce a narrative to show where in Trella's chart the adverse incidents are documented.

Tuesday's ruling clarifies and strengthens the state Supreme Court's July 2018 decision in Brugaletta v. Garcia, which held that hospitals' internal review of adverse incidents remain confidential.

The appeals court also said that Newton Medical Center is obligated under Brugaletta to rectify its failure to produce such a narrative. The panel also rejected the medical center's argument that documenting adverse events after treatment would be overly burdensome, and that the type of narrative described in Brugaletta is only required when a patient has a voluminous chart. The court also rejected the hospital's assertion that the plaintiff's request for a narrative is an effort to circumvent the privilege granted internal review of adverse events under the Patient Safety Act.

The Brugaletta decision also said rules remain in place giving plaintiffs the right to access documentation of events leading to their injuries.

The lawyer representing Trella, Ernest Fronzuto of Fronzuto Law Group in Woodland Park, also represented the plaintiff in Brugaletta.

Fronzuto said the Trella ruling was notable for requiring hospitals to provide the narrative, even if it needs to be done after the fact, and regardless of how difficult it is. The decision was also notable for its holding that the narrative is not just required for medical records that are especially voluminous.

Hospitals "want to put up a steel curtain around these investigations and say patients are not entitled to know the facts surrounding their treatment. That's not what the Patient Safety Act stands for," said Fronzuto.

The lawyer for the hospital, Peter Marra of Schenck, Price, Smith & King in Florham Park, did not return a call about the case.

Tuesday's ruling in Trella v. Bradish is "a huge win for the patients in New Jersey," said Abbott Brown, who represents plaintiffs in medical malpractice suits at Lomurro Law. "For years, hospitals have hidden behind this self-critical analysis. The court said if there is an adverse event, you've got to document it."

"You can't knowingly have an adverse event and not add it to the chart," added Jonathan Lomurro, another medical malpractice lawyer at the same firm.

Plaintiff Trella went to Newton Medical Center in January 2016 with pain in her right leg, and was diagnosed with a comminuted fracture of the right femoral shaft. Trella complained of numbness, coldness, decreased sensation and lack of mobility after orthopedic surgery. She was transferred to Morristown Medical Center, where she underwent an under-the-knee amputation of the right leg due to a blocked blood vessel.

Trella and her spouse filed a medical malpractice suit against Newton Medical Center, the treating physician and various other parties. She sought discovery of a written narrative identifying the place in her chart where adverse incidents are documented.

A trial judge ordered the hospital to provide that written narrative. At the Appellate Division, Judges Joseph Yannotti and Richard Hoffman said the trial court's order was entirely consistent with Brugaletta. The appeals court also rejected the hospital's claim that no adverse event ever occurred.

Newton Medical Center "claims that because no 'adverse incidents were recorded when Ms. Trella was treated, the task would now be 'overly burdensome.' The record does not, however, support that claim. Moreover, NMC has conceded that an 'adverse event' of some kind occurred during Ms. Trella's treatment. NMC has not convincingly explained why that event would not meet the definition of an adverse event," the appeals court said.

Newton Medical Center "also argues that the trial court erred by failing to identify the person or persons at NMC who should review Ms. Trella's chart entries and identify the 'adverse events' that were recorded there or should have been recorded. The trial court stated that it is NMC's responsibility to identify the person or persons who should perform that task. We agree," Yannotti and Hoffman stated.