Dermatology — Procedure Note Template

Pre-Procedure Assessment

Patient Information

Date: [Date]
Patient: [Name]
DOB: [Date]
Procedure location: [Clinic name/address]

Indication

Clinical diagnosis: [Pre-procedure diagnosis]
Location: [Anatomic site, laterality]
Size: [X] cm
Duration: [How long lesion present]
Symptoms: None / [Pain, bleeding, pruritus, growth]
Prior treatment: None / [Previous treatments]
Reason for procedure: [Diagnostic, therapeutic, cosmetic]

Relevant History

Anticoagulation: None / [Agent, last dose, held: Yes/No]

• INR (if applicable): [Value]
• Bridging: [If applicable]

Bleeding disorders: None / [Specify]
Implanted devices: None / Pacemaker / ICD / Other

• Manufacturer notified: Yes / No / N/A

Allergies: [Drug/latex/adhesive allergies]
Prior wound healing issues: None / [Keloid, hypertrophic scar, poor healing]
Immunosuppression: None / [Specify]
Diabetes: No / Yes — [Control status]
Pregnancy: N/A / No / Yes

Pre-Procedure Vital Signs

BP: [X/X]
HR: [X]

Pre-Procedure Photos

Taken: Yes / No

Consent

Informed consent obtained: Yes
Discussed:

• [ ] Nature of procedure
• [ ] Risks: Bleeding, infection, scarring, nerve damage, recurrence, incomplete removal
• [ ] Benefits: [Diagnosis, removal, symptom relief]
• [ ] Alternatives: [Observation, other treatments]
• [ ] Patient questions answered

Patient verbalized understanding: Yes
Consent form signed: Yes

Procedure Details

Procedure Type

[ ] Shave biopsy/removal
[ ] Punch biopsy
[ ] Excision (elliptical)
[ ] Tangential excision
[ ] Curettage and electrodesiccation
[ ] Cryotherapy
[ ] Incision and drainage
[ ] Nail procedure
[ ] Other: [Specify]

Location

Anatomic site: [Specific location]
Laterality: Right / Left / Midline
Size of lesion: [X] cm

Preparation

Timeout performed: Yes — Correct patient, site, procedure verified
Site marked: Yes / No / Not required
Site preparation: [Chlorhexidine / Betadine / Alcohol]
Sterile draping: Yes
Sterile technique: Maintained throughout

Anesthesia

Type: Local infiltration
Agent: [Lidocaine 1% / Lidocaine 1% with epinephrine / Bupivacaine]
Volume: [X] mL
Buffered: Yes / No
Field block / Direct infiltration / Nerve block ([Specify nerve])
Adequate anesthesia achieved: Yes
Epinephrine waiting time (if applicable): [X] minutes

Surgical Technique

For Shave Biopsy/Removal:

Technique: [DermaBlade / #15 blade / Scissors]
Depth: Superficial / Mid-dermal / Deep dermal
Base treatment: None / Electrodesiccation / Chemical hemostasis [Agent]
Specimen size: [X] cm
Estimated blood loss: Minimal

For Punch Biopsy:

Punch size: [X] mm
Depth: [Full thickness / To subcutaneous fat]
Specimen size: [X] cm
Closure: None / [Suture type and number]
Estimated blood loss: Minimal

For Excision:

Incision: Elliptical
Margins: [X] mm clinical margins
Excision dimensions: [X] cm x [X] cm
Depth: [To subcutaneous fat / To fascia / Specify]
Orientation marked: Yes / No — [Method: suture, ink]
Hemostasis: [Electrocautery / Pressure / Suture ligation]
Undermining: None / [Extent, depth]
Closure:

• Deep sutures: [Type, size, number]
• Superficial sutures: [Type, size, number] / Staples / Adhesive

Final closure length: [X] cm
Estimated blood loss: [Minimal / X mL]

For Curettage and Electrodesiccation (C&E):

Cycles: [1 / 2 / 3]
Curette size: [X] mm
Electrodesiccation setting: [X] watts, [Mode]
Final defect size: [X] cm
Hemostasis achieved: Yes

For Cryotherapy:

Agent: Liquid nitrogen
Application: Spray / Cotton-tip / Cryoprobe
Freeze time: [X] seconds per cycle
Thaw time: [X] seconds
Number of freeze-thaw cycles: [1 / 2]
Halo: [X] mm
Lesions treated: [Number, locations]

For Incision and Drainage:

Incision: [X] cm
Abscess size: [X] cm
Material expressed: [Purulent, seropurulent, etc.]
Cavity explored: Yes — No loculations
Irrigation: Yes — [Solution, volume]
Packing: None / [Type] / Drain placed
Culture sent: Yes / No

For Nail Procedure:

Nail: [Finger/toe, which]
Procedure: [Nail avulsion / Partial matrixectomy / etc.]
Digital block: [Type, agent]
Tourniquet: Yes — Duration: [X] minutes
Hemostasis: [Method]

Intraoperative Findings

Gross appearance: [Description of lesion]
Extension: [Superficial / Deep, well-circumscribed / ill-defined]
Unexpected findings: None / [Describe]

Complications

Intraoperative complications: None / [Describe]

• [ ] Excessive bleeding — Managed by: [Method]
• [ ] Nerve encountered — [Action taken]
• [ ] Extended excision required
• [ ] Other: [Describe]

Specimen Handling

Specimen(s) obtained: Yes
Number of specimens: [X]
Specimen identification: [How labeled/oriented]
Sent to: [Pathology lab name]
Studies requested:

• [ ] H&E (routine histology)
• [ ] Rush processing
• [ ] Special stains: [Specify]
• [ ] Direct immunofluorescence
• [ ] Culture: [Bacterial, fungal, AFB]

Orientation provided: Yes / No / N/A

• Method: [Suture at 12 o'clock / Ink marking / Diagram]

Post-Procedure

Wound Care

Dressing applied: [Type]
Pressure dressing: Yes / No
Wound care instructions provided: Written / Verbal / Both

Post-Procedure Instructions

• Keep dressing clean and dry for [X] hours
• Remove dressing after [X] hours
• Clean wound [frequency] with [solution]
• Apply [ointment/Vaseline] [frequency]
• [Specific activity restrictions]
• Avoid [strenuous activity, swimming, etc.] for [X] days
• Signs of infection to watch for: Increasing redness, swelling, warmth, purulent drainage, fever

Suture Care (if applicable)

Suture type: [Absorbable / Non-absorbable]
Suture removal: [X] days — Location: [Office / Patient / PCP]
Keep sutures dry until: [Timeframe]

Pain Management

OTC recommended: Acetaminophen / Ibuprofen / [Other]
Prescription provided: No / Yes — [Medication, quantity]

Activity Restrictions

• No heavy lifting (>[X] lbs) for [X] days
• Avoid [specific activities] for [X] days
• May return to work: [Date / restrictions]

Prescriptions

[ ] Antibiotic prophylaxis: [Medication, dose, duration] — Indication: [High-risk site, etc.]
[ ] Analgesic: [Medication, dose, quantity]
[ ] Topical: [Medication for wound care]

Follow-up Plan

Pathology results: Expected in [X] days

• Will contact patient: Phone / Portal / [Method]
• If malignant: [Plan for re-excision, referral, etc.]

Follow-up appointment: [Date] for [Suture removal / Wound check / Results discussion]
Return sooner if:

• Signs of infection
• Excessive bleeding
• Wound dehiscence
• Concerns

Provider Attestation

Procedure performed by: [Name, credentials]
Supervision (if applicable): [Attending name]
Time: Start [Time] — End [Time]
Total procedure time: [X] minutes

Billing Information

CPT code(s):

• [ ] 11102/11103 - Tangential biopsy
• [ ] 11104/11105 - Punch biopsy
• [ ] 11106/11107 - Incisional biopsy
• [ ] 1130X-1131X - Shave removal (by size and location)
• [ ] 1140X-1146X - Excision benign (by size and location)
• [ ] 1160X-1166X - Excision malignant (by size and location)
• [ ] 17000-17004 - Destruction AKs
• [ ] 17110/17111 - Destruction benign lesions
• [ ] [Other codes]

Modifier(s): [If applicable]
Diagnosis code: [ICD-10]