Laser Skin Resurfacing Procedure Note

Date: [Date of procedure]

Patient: [Patient name and identifier]

Procedure: [Laser type, modality, and anatomic site(s)] (Include fractional vs non-fractional, ablative vs non-ablative, device modality, and laterality if applicable.)

Proceduralist: [Name and credentials]

Assistant(s): [Name(s) and role(s) / None]

Location: [Facility and room type]

Procedure Summary

[Procedure summary narrative] (3–5 sentences covering: indication/goal, site(s) treated, anesthesia method, device used, HSV prophylaxis status with rationale, immediate outcome and tolerance, and complications—state explicitly "None" if no complications.)

Indication and Patient Factors

[Clinical indication, treatment intent, and patient-specific factors] (Include whether cosmetic or medically indicated. Document relevant factors: Fitzpatrick skin type, recent tanning, history of PIH or melasma, HSV history, recent isotretinoin exposure with timing. If diagnosis is documented elsewhere, reference that note and include a one-line indication here.)

Pre-Procedure

Screening: [Interval history and baseline exam findings] (Document: new medications, infections, sun exposure/tanning, pregnancy status if relevant. Confirm treatment area shows no active infection, dermatitis, open wounds, or suspicious lesions. Note any concerning findings or deferrals.)

Allergies: [Relevant allergies reviewed] (Especially topical anesthetics, antivirals, antibiotics.)

Consent: [Consent documentation] (Written consent obtained. Risks discussed: infection including HSV reactivation and bacterial, scarring, dyspigmentation, prolonged erythema, ocular injury if periocular, need for multiple sessions if applicable. Alternatives reviewed and questions answered.)

Pre-procedure photos: [Yes / No]

Time-out: [Completed] (Correct patient, procedure, site(s), equipment, and protective eyewear verified.)

Anesthesia and Prophylaxis

Topical anesthesia: [Agent, concentration, application duration, occlusion] (Omit if not used.)

Local anesthesia: [Agent, concentration, volume, epinephrine status, nerve blocks with laterality] (Omit if not used.)

Sedation: [Level, provider, and sedation record reference / None]

HSV prophylaxis: [Agent, dose, start date, duration / Not indicated with rationale] (Required field—do not leave blank. If not indicated, state rationale such as no HSV history or non-facial treatment area.)

Antibacterial prophylaxis: [Agent, dose, rationale / Not indicated] (Omit if not used.)

Laser Safety

Eye protection: [Patient protection type and verification] (Specify metal corneal shields, goggles, or wet gauze as appropriate. Confirm staff wavelength-appropriate eyewear.)

Smoke evacuation: [Yes / No]

Fire risk mitigation: [Skin prep agent, drying confirmed, oxygen status, other precautions]

Device and Parameters

(Document a separate parameter block for each device, handpiece, or treatment mode used.)

[Device/Mode Block]

Device: [Manufacturer, model, wavelength, delivery type, handpiece/tip]

Parameters: [Energy/fluence with units (mJ or J/cm²), power (W), pulse duration (ms), repetition rate (Hz), spot size, density/coverage (% or device scale), number of passes, stacking, overlap strategy, cooling method, total energy delivered] (Include all applicable parameters with explicit units.)

Parameter changes: [Settings adjusted, region, and rationale] (Document what changed, where, and why. Omit if no changes made.)

Treatment Map

Areas treated: [Anatomic regions with laterality] (e.g., full face, perioral, periorbital, specific scars with location.)

Exclusions: [Areas avoided within treatment zone and reason] (e.g., vermilion border, recent filler sites, active dermatitis. Omit if none.)

Technique: [Coverage pattern and adjunctive steps] (Uniform vs targeted high-density passes, feathering at margins, char debridement for ablative, mucosal barriers.)

Findings and Response

[Intra-procedure findings and endpoints] (Describe endpoints appropriate to modality: for ablative—erythema pattern, edema, pinpoint bleeding, tissue response, char/debris; for non-ablative—erythema, edema, grid pattern. Note whether endpoints were uniform or varied by region.)

Patient tolerance: [Pain score if obtained, overall tolerance, pauses or additional anesthesia required, early termination with reason if applicable]

Complications: [Description with timing, severity, management, and patient status / None] (Required field—state explicitly "None" if none occurred.)

Post-Procedure

Immediate care: [Cleansing/debridement, topicals applied, cooling, post-procedure photos obtained]

Instructions provided: [Aftercare instructions given] (Reference standardized instruction set by name if used. Note any patient-specific modifications.)

Medications prescribed: [Post-procedure medications with purpose and duration]

Follow-up: [Scheduled follow-up interval and return precautions reviewed] (If staged treatments planned, note anticipated number and spacing.)