Excision Procedure Note (Malignant Lesion)

Patient name: [Patient name]

DOB or MRN: [DOB or MRN]

Date: [Procedure date]

Procedure: [Procedure title, e.g., "Excision of malignant lesion with layered closure"]

Anatomic site: [Anatomic site with laterality and specific location]

Operator: [Operator name, credentials]

Facility: [Facility name]

Pre-Procedure Summary

[Pre-operative diagnosis] (If biopsy-confirmed, include pathology accession number, biopsy date, and key histologic features relevant to margin selection such as subtype, differentiation, or perineural invasion. If malignancy is suspected but not biopsy-proven, document as clinical impression and note specimen is being sent for definitive diagnosis.)

[Indication for excision] (State purpose such as definitive treatment, margin control, or management of recurrence. Include high-risk context when applicable: aggressive histology, recurrent tumor, prior radiation field, immunosuppression, high-risk anatomic location.)

[Lesion or scar measurements in mm, length × width] (If excising a prior biopsy site with no visible residual tumor, document scar size and note absence of clinically apparent residual.)

[Planned clinical margin in mm with rationale] (State whether guideline-based for risk level or modified due to anatomic constraints with mitigation plan.) [Calculated excised diameter in mm] (Lesion diameter plus two times the planned margin.)

[Pertinent patient factors] (Include only if relevant: allergies, anticoagulation status and peri-procedural plan, need for antibiotic prophylaxis. Omit this paragraph if not applicable.)

Consent and Time-Out

[Informed consent status] (Document that informed consent was obtained including discussion of risks, benefits, and alternatives. If consent was not obtained, leave blank or explicitly note.)

[Time-out status] (Document that time-out was performed confirming correct patient, procedure, site, and laterality. If not performed, leave blank or explicitly note.)

Procedure

[Patient positioning], [skin preparation with antiseptic agent], and sterile draping.

Anesthesia: [Agent and concentration], [with / without] epinephrine, [total volume in mL]. (If no anesthetic was used, state explicitly.)

Excision: [Technique, e.g., elliptical excision with scalpel] with excision plane carried [depth, e.g., through dermis into subcutaneous fat / to fascia]. Grossly visible tumor [present / absent] at time of excision.

Hemostasis: [Hemostasis method] with [estimated blood loss, e.g., minimal].

Specimen handling: Specimen submitted to pathology with container labeled using two patient identifiers plus site and laterality. Orientation: [Orientation method and key, e.g., single suture marking superior margin / short suture superior, long suture lateral / specimen submitted unoriented]. (Do not state or imply margin status unless intraoperative margin assessment was performed.)

Closure: [Repair type: secondary intention / simple / layered / complex / flap / graft]. [Undermining, if performed]. Deep layer: [Suture material, size, technique]. Epidermal closure: [Suture material, size, technique]. Final repaired length: [Length in cm]. Dressing: [Dressing applied]. (Include only the closure elements that apply.)

Immediate outcome: [Patient tolerance], [complications or none], [condition at completion].

Post-Procedure Plan

Wound care instructions provided. Suture removal in [timeframe in days]. Follow-up: [Appointment plan].

Pathology results to be communicated via [phone / portal / follow-up visit] within [expected timeframe].

Margin management: If margins negative, [plan, e.g., routine surveillance]. If margins positive or close, [plan, e.g., re-excision / Mohs referral]. (If closure was delayed pending margin confirmation, note this. If immediate closure was performed despite high-risk features, briefly document rationale.)

[Surveillance counseling] (Note if counseling was provided regarding skin exam interval and sun protection. Omit if not applicable.)