Excision Procedure Note (Benign Lesion)

Date/Time: [Procedure start date and time]

Clinician: [Proceduralist name and credentials; assistant if present]

Setting: [Clinic/office location]

Procedure Summary

[Single-line procedure summary] (Compose as: "Excision of [benign-appearing / biopsy-confirmed benign] lesion, [anatomic site with laterality]; lesion [length] × [width] cm; [planned margin width] mm margins; excised diameter [excised diameter] cm; [simple / intermediate / layered] closure; repair length [final repair length] cm." Calculate excised diameter as the largest lesion dimension plus twice the planned margin, converting mm to cm as needed.)

Indication

[Brief clinical rationale] (2–4 sentences summarizing symptoms prompting removal, relevant history of the lesion, prior treatments if any, and patient preference if it influenced the decision. Avoid extended HPI.)

Consent & Pre-Procedure Verification

[Consent obtained: verbal / written] after discussion of risks, benefits, and alternatives. Risks reviewed included [bleeding, infection, scarring, recurrence, need for further procedure, anesthesia reaction, nerve injury] as appropriate. Questions answered; patient agreed to proceed.

Allergies reviewed: [none reported / list specific allergies to local anesthetics, antiseptics, adhesives, latex, or tape].

Time-out performed prior to incision: correct patient, procedure, site, and laterality confirmed; site [marked / marking not applicable].

Lesion Description

Location: [Exact anatomic site with laterality and surface/landmark].

Appearance: [Color, morphology, texture, palpation findings, presence/absence of punctum or pedunculation].

Pre-operative size: [length] × [width] cm.

Planned margins: [margin width] mm. Planned excised diameter: [excised diameter] cm ([largest lesion dimension] + 2 × [margin]).

Anesthesia

[Local anesthetic agent] [concentration]% [with epinephrine / without epinephrine], [volume] mL, administered via [local infiltration / field block / nerve block]. [Well tolerated / tolerance issues noted]. (Do not finalize if agent, concentration, or volume is missing.)

Procedure

Skin prepared with [antiseptic], area draped in sterile fashion. [Elliptical / fusiform] incision oriented [along / across] relaxed skin tension lines. Excision performed [full-thickness through dermis into subcutaneous tissue / to specified depth], removing lesion with planned margins. Hemostasis achieved with [pressure / electrocautery / suture ligation]. Intraoperative findings: [intact capsule, ruptured contents, clinically clear margins, other notable findings]. Actual excised diameter: [cm] (include if different from planned). Complications: [none / describe event and management]. (Do not state "complete excision" unless clinically certain; if margins uncertain, defer to pathology.)

Closure

[Primary closure / secondary intention]. [Layered / single-layer] closure. Undermining: [none / minimal / moderate / extensive]. Deep layer: [suture material and size], [buried interrupted / other technique]. Superficial layer: [suture material and size / adhesive strips / tissue adhesive], [simple interrupted / running / mattress / other technique]. Final repaired wound length: [cm]. Dressing: [dressing type applied]. (Do not finalize if closure type or final repair length is missing.)

Specimen

Specimen [submitted to pathology / not submitted]. (If sent: note container labeled with two patient identifiers, specimen site, and laterality; fixative used; orientation markers if placed. If multiple specimens, list each separately with container designation. If not sent, document reason and that patient was informed.)

Post-Procedure & Aftercare

Patient [tolerated procedure well / other]; hemostasis achieved.

Wound care: [cleaning and dressing change instructions]. Activity: [restrictions if any]. Pain control: [acetaminophen / NSAIDs / other]. Warning signs reviewed: redness, warmth, drainage, fever, uncontrolled bleeding, wound separation—seek care if these occur. Pathology results: [how and when results will be communicated].

Suture removal: [planned timeframe based on site: face 3–5 days, scalp/arms 7–10 days, trunk/legs 10–14 days, hands/feet 10–14 days, palms/soles 14–21 days / absorbable sutures, no removal needed]. (Do not finalize if nonabsorbable sutures placed without a removal plan.)

Diagnoses

Pre-operative diagnosis: [Clinical impression]

Post-operative diagnosis: [Same as pre-op pending pathology / updated if known]

Pathology status: [Pending / Sent / Not sent (reason)]

Addendum – Pathology Results

(Add when pathology returns.) Final diagnosis: [diagnosis]. Margin status: [clear / involved / close / not reported]. Additional management: [re-excision, referral, surveillance, suture removal timing change, none]. Results communicated to patient: [method and date].

(If multiple lesions excised in the same encounter, repeat Lesion Description through Specimen sections for each lesion.)