Curettage and Electrodesiccation Procedure Note

Date/Time of Procedure: [Date and time of procedure]

Performing Clinician: [Name, credentials]

Location: [Clinic/procedure room]

Procedure Summary

[Brief 1–3 sentence narrative summary including procedure performed (ED&C), diagnosis, anatomic site with laterality, number of curettage/desiccation cycles completed, final defect size, and hemostasis statement]

Indication

(Create a separate block for each lesion treated, numbered sequentially.)

Lesion #1

• Diagnosis: [Biopsy-proven with pathology date and histologic type / Clinical diagnosis with brief rationale]
• Anatomic Site: [Specific location with laterality]
• Pre-procedure Lesion Size: [Size in cm]
• Rationale for ED&C: [Brief rationale for selecting ED&C]

(Repeat Lesion # block for each additional lesion.)

Pertinent Risk Factors

(Include only factors directly relevant to ED&C. If none apply, state "None identified" or omit this section.)

• Anticoagulant/Antiplatelet Use and Plan: [Agent(s) and peri-procedural management / None]
• Immunosuppression: [Status and details / None]
• Relevant Allergies: [Anesthetic, antiseptic, or adhesive allergies / None]
• Implanted Cardiac Devices: [Device and electrosurgery precautions / None]

Informed Consent

[Written / Verbal] consent obtained per policy. Risks discussed included [bleeding, infection, scarring, recurrence, pigment change]. Alternatives discussed included [excision, Mohs surgery, topical therapy, observation] as appropriate. Patient verbalized understanding and agreed to proceed.

(This section must always be completed. If consent not explicitly documented, insert "[Consent not documented]".)

Pre-procedure Verification

Time-out performed verifying correct patient (two identifiers), correct procedure (ED&C), correct site with laterality [and site marking if required].

Anesthesia

• Agent: [Name and concentration]
• Volume: [Total volume in mL]
• Epinephrine: [Yes / No]
• Route: [Local infiltration / Field block / Other]

Procedure Details

(Create a separate subheading for each lesion treated with its own complete set of fields.)

Lesion #1 – [Diagnosis] – [Site]

• Cycles Performed: [Number of cycles with technique description, e.g., "Three cycles of curettage to firm dermis with electrodesiccation of base and margins after each cycle"]
• Final Defect Size: [Length × width in cm] (If not provided, insert "[Final defect size not documented]".)
• Hemostasis: [Method: electrodesiccation / pressure / hemostatic agent]; [adequate hemostasis achieved / describe if incomplete]
• Specimen: [Specimen description and destination / No specimen sent]
• Complications: [None / Complication and management]
• Patient Tolerance: [Tolerated procedure well / Other]

(Repeat subheading and fields for Lesion #2, Lesion #3, etc.)

Wound Care

• Dressing Applied: [Type of dressing, e.g., petrolatum with nonadherent pad and tape]
• Instructions Provided: [Summary of aftercare including wound cleaning frequency, moist healing with ointment, bleeding precautions, signs of infection warranting contact, activity restrictions]. [Written instructions provided / Verbal instructions only].

Follow-up

Patient discharged in stable condition. [Follow-up plan including wound check timing if indicated and skin cancer surveillance interval]. (If pathology pending, document plan for result notification and contingency for higher-risk findings.)

Clinician Signature

[Electronic signature of performing clinician with credentials]