Cryotherapy Procedure Note (Benign Lesions)

Date/Time of Procedure: [Date and time]

Clinical Setting: [Outpatient clinic / Urgent care / Procedure room / Other]

Operator: [Name, credentials]

Patient: [Per EHR/organizational policy]

Procedure Summary

[Brief summary of procedure performed: cryotherapy/cryosurgery with liquid nitrogen for destruction of benign lesions; include lesion type(s), total number of lesions treated, and general anatomic regions treated.] (Keep to 1–3 sentences. Ensure total lesion count matches the Lesion Inventory.)

Diagnosis and Indication

Pre-Procedure Diagnosis: [Benign lesion type(s): verruca vulgaris / plantar wart / seborrheic keratosis / actinic keratosis / molluscum contagiosum / other]

Indication/Medical Necessity: [Pain / Pruritus / Bleeding / Recurrent trauma / Inflammation / Spread / Obstruction / Cosmetic request] (Specify concrete symptoms or functional effects; avoid vague terms. If cosmetic only, explicitly state cosmetic request.)

Clinical Certainty: [Clinically consistent with benign lesion / Uncertain etiology – biopsy performed today / Uncertain etiology – biopsy planned / Benign confirmed on prior pathology, date]

Post-Procedure Diagnosis: [Same as pre-procedure / Revised diagnosis]

Consent

Consent Type: [Verbal / Written / Both]

Risks Discussed: Pain, blistering, bleeding, infection, scarring, pigment change, incomplete resolution/recurrence, need for repeat treatment.

Benefits Discussed: Lesion destruction, symptom relief, reduced spread.

Alternatives Discussed: Observation, topical therapy, curettage/shave, biopsy/excision, referral.

Patient questions answered and consent obtained.

Pre-Procedure Verification

Verification: Correct patient, procedure, and sites verified. Time-out: [Yes / Not required per policy]. Allergies reviewed: [Yes / Yes – relevant allergy noted]

Contraindication Screening: [No contraindications identified / Positive finding] (Screen for cold urticaria, cryoglobulinemia, Raynaud phenomenon, impaired circulation, sensory loss, immunosuppression.)

Lesion Inventory

(List each lesion precisely with laterality and anatomic landmarks. Grouping acceptable only if locations remain specific. Total must reconcile with Procedure Summary. Do not infer lesion count, location, or laterality—if uncertain, document the uncertainty.)

Lesion #	Clinical Diagnosis	Location (laterality + landmark)	Symptom/Trigger	Size (mm)
[1]	[Diagnosis]	[Side and precise location]	[Pain / Pruritus / Bleeding / Recurrent trauma / Spread / Obstruction / Asymptomatic]	[Size if relevant]
[2]	[Diagnosis]	[Side and precise location]	[Symptom/Trigger]	[Size if relevant]

(Add rows as needed.)

Total lesions treated: [Number]

Procedure Details

Cryogen/Method: Liquid nitrogen; [Spray / Cotton-tip applicator / Probe]; Confined spray guard: [Yes / No / N/A]

Skin Prep: [None / Alcohol / Antiseptic]

Anesthesia: [None / Agent, concentration, volume, route] (Document "none" explicitly if not used.)

Technique: Freeze applied until adequate ice ball encompassed lesion with appropriate margin. Freeze–thaw cycles: [Number]. Freeze time per cycle: [Seconds or range]. Thaw time between cycles: [Seconds]. (Document per lesion if parameters varied; otherwise, group statement acceptable.)

Hemostasis/EBL: [None / Minimal / Specify]

Specimens: [None / Tissue obtained – type and disposition]

Patient Tolerance and Outcome

Tolerance: [Tolerated well / Discomfort managed / Other]

Completion Status: [All intended lesions treated / Partial – specify lesions deferred and reason]

Immediate Outcome: [Expected frost/ice ball achieved, no immediate adverse events / Other]

Complications

[None / Complication and management] (Never leave blank. If complication occurred, specify type and management provided.)

Post-Procedure Care

Instructions Provided: [Verbal / Written handout / Both]

Follow-up Plan: [PRN / Scheduled re-treatment in X weeks / Follow-up visit in X weeks]

Return precautions discussed.

Signature

Operator: [Electronic signature and credentials]