Mass Removal/Biopsy Procedure Note

Date/Time of Procedure: [Date and time]

Location: [Clinic/office location]

Patient Name: [Full name]

DOB: [Date of birth]

MRN: [Medical record number]

Proceduralist: [Name, credentials]

Assistant: [Assistant name and role] (Include only if an assistant participated.)

Procedure Summary: [Procedure type: excisional biopsy / punch biopsy / shave biopsy / other] — [Number of lesions addressed] — [Anatomic site(s) with laterality] — [Closure method]

Indication

[Reason for procedure including presenting concern, working diagnosis or differential if relevant, and rationale for technique chosen] (Clearly document symptoms or functional impact for benign-appearing lesions to justify medical necessity beyond cosmetic concern. Avoid vague terms like "irritated lesion" without further justification.)

Pre-Procedure Assessment

(Omit this section entirely if no pertinent risk modifiers exist.)

• Allergies: [Relevant allergies to local anesthetics, prep agents, latex, adhesives]
• Bleeding risk: [Anticoagulants/antiplatelets, coagulopathy, relevant labs if available]
• Infection risk: [Immunosuppression, diabetes, prosthetic devices/valves]
• Pregnancy/lactation: [Status if relevant to technique or medications]

Safety Verification

Informed Consent: [Written / verbal] consent obtained. Risks discussed including [bleeding, infection, scarring, wound dehiscence, nerve injury, recurrence, need for further surgery]. Alternatives discussed, questions answered, patient agreed to proceed. (Include only if consent was obtained.)

Pre-Procedure Verification: Two-identifier patient verification completed. Intended procedure and intended site(s) with laterality confirmed. (Include only if performed.)

Site Marking: [Site marked by whom, method used, patient participation] (Include only if performed. If not required per institutional policy, state "Not required per policy" with brief rationale.)

Time-Out: Time-out performed immediately before incision. Participants: [List participants]. Verbal confirmation of patient identity, procedure, and site/laterality completed. (Include only if performed.)

Procedure Details

(Repeat the Lesion # sub-block for each lesion addressed. Do not combine multiple lesions into a single block.)

Lesion #1

Location: [Exact anatomic site with laterality, distance to landmarks if relevant, brief appearance descriptors if clinically meaningful]

Measurements:

• Pre-procedure lesion size: [Greatest diameter or length × width] (If not documented, insert: [REQUIRED: lesion size not documented])
• Planned margin: [Margin in mm] (For excisions. If not documented, insert: [REQUIRED: excision margin not documented])
• Calculated excised diameter: [Lesion + margins] (For excisions.)
• Post-excision defect size: [Dimensions if measured] (For excisions.)
• Final closure length: [Length] (Required for excisions with closure. If not documented, insert: [REQUIRED: final closure length not documented])
• Specimen size: [Dimensions] (For shave/punch/incisional biopsy; margins not applicable.)

Positioning and Prep: [Patient position] — [Skin preparation agent] (If alternative prep used due to allergy or contraindication, document reason.)

Anesthesia: [Medication name, concentration, with/without epinephrine] — [Local infiltration / field block] — Total volume: [Volume in mL] — [Patient tolerance or adverse reaction] (Anesthetic volume must be explicitly stated. If not documented, insert: [REQUIRED: total anesthetic volume not documented])

Technique: [Instrumentation used including blade type, punch size, or needle gauge] — [Incision type and orientation relative to skin tension lines if relevant] — [Depth/plane of dissection: dermis / subcutaneous fat / fascia] — [Intact / piecemeal removal] — [Key intraoperative findings such as cyst rupture, purulent contents, gross appearance] — [Hemostasis method: pressure / electrocautery / chemical agents / suture ligation] — Estimated blood loss: [Volume or "minimal"]

Closure: [Closure type: none-secondary intention / adhesive / simple / layered] — [Layers closed] — [Suture type and size per layer] — [Technique: simple interrupted / running / buried dermal / other] — Final wound length: [Length] — Dressing: [Materials applied] (If no closure performed, state reason.)

Lesion #2

(Repeat structure above for each additional lesion addressed.)

Specimen

(Create a separate entry for each specimen. Align specimen identifiers with lesion numbers.)

Specimen A

• Identifier: [A / B or #1 / #2 corresponding to lesion number]
• Source site: [Anatomic site with laterality]
• Specimen type: [Shave / punch / excision / core / FNA]
• Gross size: [Dimensions if known]
• Fixative/medium: [Formalin / microbiology transport / cytology medium / other]
• Orientation markers: [Orientation details if used, e.g., "short suture marks superior"]
• Destination laboratory: [Laboratory name]
• Clinical history on requisition: [Relevant history communicated to pathology]

Specimen B

(Repeat as needed for each additional specimen.)

Complications and Patient Condition

Complications: [None / description of complication and management]

Patient condition: [Tolerance and condition at procedure completion, e.g., "Patient tolerated procedure well, stable, ambulatory at completion"]

Follow-Up Plan

• Suture removal: [Timeframe and location]
• Wound check: [Plan if indicated for high-risk closure or site] (Include only if applicable.)
• Pathology results: [Who will contact patient, expected timeframe, method of communication]
• Contingency plan: [Plan for malignant or margin-positive results, e.g., re-excision pathway, referral]

Attestation

[Proceduralist signature and credentials]