Laser/Skin Resurfacing Procedure Note

Date and time of procedure: [Date and time]

Location/setting: [Clinic location / Procedure room]

Performing clinician: [Name, credentials] (Include assistant or laser operator if different from performing clinician.)

Procedure type(s) performed: [ablative laser resurfacing / nonablative laser resurfacing / fractional laser resurfacing / IPL photorejuvenation / chemical peel — superficial / medium-depth / deep] (Select all that apply.)

Indication and Treatment Plan

[Summary of today's procedure] (Begin with a one-sentence summary clearly stating what was performed today.)

[Primary indication and treatment goal; anatomic area(s) treated with subunit specificity; session context] (In 1–3 additional sentences, state the diagnosis or cosmetic concern, desired outcome, precise anatomic areas/subunits treated, and whether this is an initial or follow-up session with treatment number in series if applicable. If relevant, clarify medical necessity vs cosmetic.)

Skin Assessment and Risk Stratification

• Fitzpatrick skin phototype: [I / II / III / IV / V / VI] ([qualifiers such as baseline dyspigmentation, current tan, recent sun exposure])
• Treatment target characterization: [Erythema/telangiectasia pattern and distribution / Pigment distribution and quality / Scar type and morphology / Lesion description] (Concise description relevant to the modality.)
• Pertinent risk factors:
  • [History of hypertrophic scarring or keloids: details]
  • [Isotretinoin use (current or recent): timing and how risk was addressed]
  • [HSV history relevant to perioral/full-face treatment: prophylaxis plan if used]
  • [Tendency for PIH or melasma: baseline risk and counseling]
  • [Photosensitizing medications and/or recent UV exposure/tan: details and adjustments]
  (Include only risk factors that are present; omit sub-bullets for absent risks without placeholder text.)

Informed Consent

Informed [written / verbal] consent was obtained per policy and documented in the chart for [modality/modalities] to [anatomic site(s)]. (If consent was not obtained due to an exceptional circumstance, explicitly document the reason.)

• Risks reviewed: [burns/blistering / infection including HSV reactivation / PIH or hypopigmentation / scarring / prolonged erythema / ocular injury risk / need for multiple sessions / incomplete response] (Tailor to modality.)
• Alternatives discussed: [Alternative procedures, topical therapies, observation, defer treatment]
• Patient questions answered and understanding confirmed.

Time-Out and Verification

• Correct patient confirmed
• Correct procedure confirmed
• Correct site(s) confirmed
• Time-out performed immediately before treatment with team participation
• [Site marking used / Site marking not applicable]

(If time-out was not performed, document the reason.)

Pre-Procedure Preparation

• Anesthesia: [none / topical / local infiltration / nerve block] — [agent name], [concentration], [volume mL], [total dose mg], [mg/kg if indicated]. (For topical anesthetics: specify application site(s), occlusion method, and duration.)
• Skin cleansing: [cleansing agent used]
• Eye protection: Patient: [goggles / metal corneal shields for periocular treatment]. Staff: wavelength-appropriate eyewear worn. (If eye protection was not used, document reason.)
• Cooling method: [contact cooling / cryogen spray / cold air / chilled gel / none]
• Smoke/plume management: [Smoke evacuator used / Not applicable]
• Test spot: [performed at (location) with (observed response) / not performed]

Procedure Details

Device identification: [Manufacturer], [Model/Platform], [Handpiece or applicator type], [Laser wavelength (nm) or IPL filter/cutoff (nm)]. (For chemical peels: [peeling agent(s)], [concentration(s)], [neutralizer if applicable].)

Parameters by anatomic area: (Include only the parameter set relevant to the modality used.)

• [Anatomic area/subunit]:
  • Laser: [Spot size (mm)], [Fluence (J/cm²)], [Pulse duration], [Density/Coverage], [Number of passes], [Cooling settings], [Endpoint observed]
  • IPL: [Filter/Cutoff (nm)], [Fluence (J/cm²)], [Pulse structure], [Number of passes], [Endpoint observed]
  • Chemical peel: [Agent/Concentration], [Number of coats], [Application time], [Endpoint], [Neutralization time if applicable]

(Repeat for each anatomic area treated. If specific device settings are not available, state: "Device settings not available; see device log.")

Technique narrative: [Patient positioning, treatment sequence, parameter adjustments and rationale, patient tolerance] (3–6 sentences, past tense, chronologic.)

Outcome and Complications

Immediate outcome: [Intended endpoints achieved / partial endpoints / not achieved] — [brief description of observed clinical endpoint].

Complications: [None / Specify event and immediate management]

Estimated blood loss: [None / Minimal / Approximate volume]

Specimens: [None / Specify]

Aftercare and Disposition

• In-clinic application: [ointment / dressing / cooling / sunscreen applied] (Specify product(s).)
• Patient instructions reviewed: [expected course, photoprotection requirements, activity restrictions, wound care regimen, medication plan, warning signs warranting contact] (Tailor to modality and treated areas.)
• Written instructions provided: [Yes / No]
• Follow-up: [Timeframe] for [purpose]
• Disposition: [Discharged home in stable condition / Other]