Cryotherapy Procedure Note (Benign/Premalignant Lesion)

Date/Time: [Procedure date and time]

Location: [Clinic/site]

Performing Clinician: [Name, credentials]

(Meta: Fill all critical fields; state "N/A" where not applicable. Lesion counts in Procedure Summary must match Lesion Inventory. Use appropriately uncertain diagnostic language such as "clinically consistent with" when histology is unavailable. If any lesion is suspicious for malignancy, do not use this template—document biopsy/diagnostic plan instead. Omit irrelevant sections rather than leaving empty placeholders.)

Procedure Summary

[Brief 2–4 line synopsis: Liquid nitrogen cryotherapy performed for [benign / premalignant / both] lesions. Total lesions treated: [count]; if both types, specify benign [count] and premalignant [count]. Anatomic distribution: [concise site summary]. Tolerance/complications: [well tolerated with no immediate complications / specify]].

Indication & Diagnosis

[Indication: e.g., premalignant lesion treatment, symptomatic benign lesion, infectious lesion with patient preference]. [Pre-procedure diagnosis using appropriate uncertainty: "Clinically consistent with [suspected diagnosis]"; include histologic confirmation only if available]. [If relevant, state whether treatment is medically necessary vs cosmetic].

Lesion Inventory

(This section is the source of truth for counts and locations.)

(For 1–3 lesions, use bullet format below; for >3 lesions, use table format and omit bullets.)

• Lesion [#]: [Benign / Premalignant] — [Suspected diagnosis]. Site: [Anatomic location, laterality]. Quantity: [count]. Size: [mm or range]. Description: [concise morphology]. Symptoms: [if relevant to medical necessity / N/A]. High-risk proximity/protection: [if near eye, mucosa, digit—specify protective measures / omit if N/A].
• (Add additional lesion entries as needed.)

Category & suspected diagnosis	Site & laterality	Qty	Size (mm)	Clinical description	Symptoms/necessity	High-risk proximity & protection
[Benign / Premalignant — diagnosis]	[Anatomic site, side]	[#]	[size]	[morphology]	[symptoms / N/A]	[protection used / N/A]
(Add rows as needed. Group similar lesions by site/diagnosis if appropriate.)

Informed Consent

[Verbal / Written] consent obtained. Risks, benefits, and alternatives discussed; patient [agreed to proceed / declined]. Key risks discussed: pain/burning, blistering (clear or hemorrhagic), infection, scarring, dyspigmentation (hypo- or hyperpigmentation, may be prolonged or permanent), and recurrence requiring repeat treatment. [Site-specific risks if relevant: e.g., ocular injury, nail dystrophy / omit if N/A]. Alternatives reviewed: [observation / topical therapies / curettage / excision / biopsy] as appropriate.

Procedure Details

• Preparation: [Patient positioning; skin prep if performed; protective measures such as shields/barriers near sensitive structures / N/A].
• Anesthesia: [None / agent, concentration, route, site].
• Cryogen & delivery: Liquid nitrogen via [spray / cotton-tipped applicator / cryoprobe].
• Freeze–thaw parameters: [Number] cycle(s); freeze duration [seconds] or until [ice ball with X mm margin]; thaw time between cycles [seconds / N/A if single cycle]. (If technique varied by lesion type, specify separately: e.g., "AKs: 1 cycle × 10 sec; verrucae: 2 cycles × 15 sec each.")
• Intra-procedure events: [None / specify: bleeding, vasovagal symptoms, other].

Immediate Outcome

Tolerance: [well / fair / poor]. Blood loss: [none / minimal]. Complications: [none / specify]. Condition at end: [stable; dressing applied / no dressing required]. Disposition: [discharged in stable condition].

Post-Procedure Counseling

• Expected local reaction: Reviewed redness, swelling, tenderness, blistering (clear or blood-filled), crusting/scabbing, and potential pigment change (lighter or darker, may be prolonged or permanent).
• Wound care: [Gentle cleaning, keep clean, petroleum ointment if indicated, do not pick scab, blister management per clinic protocol].
• Return precautions: Increasing redness/warmth/swelling/pain, drainage or pus, fever, uncontrolled bleeding, or lesion persistence beyond expected healing.
• UV protection & surveillance: (Include for premalignant lesions) [Sun protection and skin self-exam/dermatologic follow-up discussed].

Follow-Up Plan

[Follow-up interval or PRN criteria]. [Plan for persistent/recurrent lesions and re-treatment expectations if applicable]. [Additional referrals if needed / N/A].

Signature: [Clinician name, credentials, date/time]