Cryotherapy Procedure Note (Premalignant Lesions)

Date and time of procedure: [Date and time]

Location/setting: [Office / clinic / procedure room]

Proceduralist: [Name, credentials]

Clinical Indication

[Pre-procedure diagnosis (e.g., actinic keratoses)] [Clinical basis for diagnosis (brief exam descriptors of lesions and distribution on sun-exposed skin)]. [Why cryotherapy is appropriate today (e.g., limited number of discrete lesions amenable to lesion-directed destruction, patient preference, prior response)]. [Confirm that selected lesions are clinically appropriate for destruction without histologic examination; any lesions concerning for malignancy are excluded from treatment and scheduled for biopsy]. (Summarize in 2–4 concise sentences; do not duplicate details documented elsewhere.)

Lesion Inventory

Total lesions treated: [Integer]. (This number must be explicit. If the total count or locations are missing from the dictation, explicitly state: "Lesion inventory incomplete: total count and/or anatomic locations not fully documented.")

(Use one of the following documentation formats based on lesion number; do not use both.)

Structured Lesion List

1. Lesion 1: [Anatomic site with laterality] [Optional notes: hypertrophic, recurrent, symptomatic, prior treatment]
2. Lesion 2: [Anatomic site with laterality] [Optional notes]
3. Lesion 3: [Anatomic site with laterality] [Optional notes]
4. (Add additional numbered items as needed to match the total count.)

Region-Based Tally

Distribution:

• [Region (e.g., scalp, forehead, cheek, dorsal hand)]: x[count]
• [Region]: x[count]
• [Region]: x[count]
• (Add lines as needed; counts by region should sum to the total lesions treated.)

Informed Consent

Consent obtained from [patient / surrogate (relationship: [relationship])]. The nature and purpose of cryotherapy were explained, including risks of pain, blistering, infection, scarring, pigmentary change, alopecia in hair-bearing areas, recurrence, and rare nerve injury. Alternatives discussed included observation, topical field therapy, photodynamic therapy, and biopsy/excision when indicated. Questions were invited and answered; the patient agreed to proceed. Consent was [verbal / written].

Safety Verification

Patient identity verified and procedure confirmed as cryotherapy for premalignant lesions; treatment sites reviewed. (Omit this section if site policy does not require time-out documentation for office-based cryotherapy.)

Procedure Details

Cryogen: [Liquid nitrogen]. Delivery method: [Spray / contact probe / cotton-tipped applicator]. Skin preparation: [None / cleansing with alcohol]. Anesthesia: [None / topical ([agent]) / local infiltration ([agent, concentration, total volume])]. (Include anesthesia details only if used.)

Technique: [Note if hyperkeratotic lesions were gently debulked prior to freezing]. Freeze applied until visible ice ball/halo extended beyond lesion margin by approximately [margin in mm]. Number of freeze–thaw cycles: [integer]. Freeze time per cycle: [seconds]. (Document freeze time only if actually timed; otherwise omit and rely on endpoint-based descriptor.) Thaw allowed to complete between cycles. [Additional technique notes as applicable].

Immediate Outcome

Patient tolerance: [Tolerated well / describe discomfort and management]. Complications: [None / describe]. Post-procedure condition: [Stable / other]. Written aftercare instructions provided; return precautions reviewed.

Follow-Up

Recheck treated sites in [timeframe]. [Skin surveillance interval if applicable]. Return sooner for re-evaluation and possible biopsy if treated lesions persist, ulcerate, or change after expected healing.

Signature

Electronically signed by: [Name, credentials]