Chemical Peel Procedure Note

Date: [Procedure date]

Time: [Start time; end time if tracked]

Patient: [Patient name and identifier]

Location/Setting: [Clinic/procedure room/facility]

Clinician: [Performing clinician name and credentials]

Assistant/Chaperone: [Name and role] (Include only if present; omit line entirely if none.)

(Agent name, concentration, endpoint achieved, and neutralization/termination method are safety-critical and must be explicitly documented. Omit sections that do not apply rather than marking "N/A." For safety screening items not obtained, document "not assessed.")

Indication and Diagnosis

[Diagnosis/indication]; [treatment area(s) with laterality and extent]; [clinical context justifying peel selection and depth]. (Use diagnosis terminology.)

Procedure Overview

• Peel depth: [superficial / medium / deep]
• Session context: [Single treatment / Session #[number] of [total] in planned series] (Include only if part of a series.)

Pre-Procedure Assessment

• Fitzpatrick skin type: [I / II / III / IV / V / VI / not assessed]
• Baseline skin status in treatment area: [Normal / active dermatitis / erosions / infection / other finding / not assessed]
• HSV history: [Positive / Negative / Unknown / not assessed]; Prophylaxis plan: [Agent and duration / not indicated / not assessed]
• History of PIH, hypopigmentation, scarring, or keloids: [Present (specify) / Absent / Unknown / not assessed]
• Isotretinoin use (current or recent): [Yes (timing: [duration since last dose]) / No / Unknown / not assessed]
• Recent procedures near treatment area: [Procedure type and date / none / not assessed]
• Allergies to peel components: [List / none known / not assessed]
• Pregnancy/lactation status: [Yes / No / Not applicable / not assessed] (Include only if relevant to agent selection per policy.)

Informed Consent

[Summary of consent discussion including nature/purpose, expected benefits, material risks tailored to peel depth and patient risk profile, alternatives including no treatment, and opportunity for questions. Patient verbalized understanding and consented.] Consent type: [Written and signed / verbal]. (For medium/deep peels, include discussion of prolonged healing and wound care requirements.)

Pre-Procedure Setup

• Cleansing/degreasing: [Method and agents used]
• Eye protection: [Goggles / shields / occlusive pads / other] (Required; explicitly document.)
• Barrier ointment placement: [Anatomic landmarks protected (e.g., commissures, alar grooves, canthi, vermilion border)] (Required; explicitly document.)
• Analgesia/anxiolysis: [None / topical anesthetic (agent, application time) / regional block (agent, dose) / oral agent (drug, dose, timing) / other]

Peel Agent(s) and Application

(Repeat the following subsection for each peel agent used. Agent name and concentration are required for every agent.)

Agent [#]: [Agent name] [Concentration/strength]

• Manufacturer/brand: [Manufacturer/brand / not documented]
• Applicator type: [Gauze / cotton-tipped applicator / brush / fan brush / other]
• Treatment area(s): [Anatomic areas with laterality; zones if delineated]
• Number of coats/passes: [Number per zone if varied]
• Contact time per layer: [Time / not applicable]
• Clinical endpoint achieved: [Erythema grade / uniform erythema / speckled frosting / uniform white frost / patient-reported burning level / other description] (Required; document explicitly.)
• Focal spot treatments or protocol deviations: [Description with rationale / none]

Technique narrative: [Brief description of application sequence, handling of sensitive areas, patient tolerance, and any intra-procedure interventions (fan, cooling, pauses).]

Neutralization/Termination

(Required for every peel. Document explicitly; do not infer from peel type.)

• Status: [Neutralized / Self-terminating / Removed/washed off]
• Details: [If neutralized: agent, method, timing, confirmation of endpoint (burning resolved, skin rinsed). If self-terminating: explicitly state no neutralization required and note observation period. If removed/washed off: timing and method.]

Immediate Post-Procedure Status

• Skin response at completion: [Erythema level, frosting status, edema, blistering if any]
• Pain/discomfort level: [Patient-reported level or descriptor]
• Complications/adverse reactions: [Description and management / none]
• Products applied in clinic: [Cool compresses / occlusive ointment / moisturizer / dressings / medications initiated]
• Vital signs: [Values] (Include only if sedation used or required for deep peels per policy; otherwise omit.)
• Disposition: [Stable and discharged / observed in clinic / other]

Aftercare Plan

• Wound care: [Cleansing instructions; occlusive or moisturizer type and application frequency]
• Activity restrictions: [Heat/exercise avoidance window; avoid waxing/exfoliants until healed; do not pick or peel]
• Sun protection: [Strict photoprotection; sunscreen start timing and reapplication; behavioral measures]
• Medications prescribed: [Antiviral prophylaxis (agent/dose/duration) / pain control / none] (Include only if prescribed.)
• Expected course: [Timeline for erythema and peeling appropriate to peel depth]
• Warning signs requiring contact: [Increasing pain, purulence, spreading erythema, grouped vesicles, excessive blistering, delayed healing]; Contact: [Clinic phone/instructions]
• Follow-up: [Appointment timing; series planning if applicable]
• Written instructions provided: [Yes / No]