Minor Office Procedure Note (Skin/Soft Tissue)

Date/Time: [Procedure date and time]

Location: [Clinic or setting]

Clinician: [Performing clinician name and credentials]

Procedure: [Cryotherapy / Shave biopsy / Punch biopsy / Simple excision / Incision and drainage / Other]

Pre-procedure Diagnosis: [Indication or working diagnosis]

Post-procedure Diagnosis: [Diagnosis based on intra-procedural findings]

Anatomic Site(s): [Laterality and precise location using anatomic landmarks] (If multiple sites, list each with clear identifiers such as Lesion A, Lesion B.)

Indication

[Brief narrative of why the procedure is being performed today] (1–3 sentences summarizing symptoms, clinical concern, failed conservative treatment, and/or suspected diagnosis. Include medical context only if it directly affects technique or aftercare, such as anticoagulation or immunosuppression.)

Target Site Description

(For single straightforward lesions, document inline. For multiple lesions, use site identifiers to prevent wrong-site errors.)

• [Lesion identifier]: [Anatomic location with laterality and landmark]; [Clinical description including morphology and appearance]; [Size in mm or cm] [measured / estimated]; [Clinical impression]
• (Add additional items for each additional lesion or site.)

Pre-Procedure Verification

• Patient identification: [Method used to confirm identity] (Use two identifiers.)
• Site verification: [Confirmation of intended procedure and site(s) with patient]; [Site marking performed / Site marking not performed: rationale]
• Time-out: [Time-out performed immediately before starting; correct patient, site, and procedure confirmed with team members present]
• Risk screening:
  • Allergies (medications, latex, antiseptics): [Specific allergies / Denies]
  • Anticoagulant/antiplatelet use: [Agent and status: held or continued / Denies / Not assessed]
  • Pacemaker/ICD: [Present / Denies / Not applicable] (Include if electrocautery planned.)

Informed Consent

[Consent discussion narrative] (Document: confirmation of patient capacity or surrogate authorization; explanation of nature and purpose; material risks discussed tailored to procedure type; benefits and alternatives including no treatment; questions answered; patient agreement. Note whether written consent signed or verbal consent obtained. Note interpreter use if applicable.)

Anesthesia

Type: [None / Topical / Local infiltration / Field block / Digital block]

Medication: [Agent and concentration]; Volume: [Total mL]; Site: [Injection location and method]; Tolerance: [Patient response]

(If no anesthesia used, state "No anesthesia required" and omit medication details.)

Preparation and Technique

[Patient positioning]; [Skin antiseptic used] and allowed to dry; [Sterile / Clean] technique with [Glove type]; [Draping if used]; [PPE for splash risk if relevant].

Procedure Details

[Chronological narrative of procedure performed] (Describe technique, key intra-procedural findings, hemostasis method, closure method if performed including suture material, size, number, and technique, and dressing applied. For multi-lesion procedures, clearly document each site using established identifiers.)

• Blood loss: [Minimal / Estimated amount in mL]
• Complications: [None / Description]
• Patient tolerance: [Well tolerated / Tolerated with discomfort / Other]

Procedure-Specific Details (Include only the section relevant to procedure performed.)

• Cryotherapy: [Method: spray or probe]; [Freeze duration in seconds per cycle]; [Number of cycles]; [Number of lesions treated]; [Immediate tissue response]
• Shave biopsy: [Tool and technique]; [Depth]; [Hemostasis method]
• Punch biopsy: [Punch size in mm]; [Depth]; [Closure: suture type, size, number, and technique / Secondary intention]
• Excision: [Lesion size]; [Planned margins]; [Excision depth]; [Undermining: performed with extent / Not performed]; [Closure layers and materials]; [Final repaired length in cm]
• Incision and drainage: [Incision type and length]; [Loculations: broken up / Not present]; [Drainage description and amount]; [Irrigation: solution and volume]; [Packing: type and amount / None]; [Culture obtained: yes / no]

Specimens

(Include this section only if tissue or fluid was sent for laboratory analysis. Omit entirely if no specimens collected.)

• [Specimen label and corresponding site identifier]: [Specimen type]; [Destination: pathology / microbiology]; Container labeled at point of collection per protocol; [Clinical information on requisition]
• (Add additional items for each additional specimen.)

Post-Procedure

• Immediate status: [Patient condition after procedure] (Include neurovascular status if relevant to site.)
• Wound care: [Dressing applied]; [Care instructions provided]; [Written instructions given: yes / no]
• Pain management: [OTC analgesia recommended / Prescription: drug, dose, frequency, quantity]
• Antibiotics: [Drug, dose, frequency, duration, and indication] (Omit if not prescribed.)
• Activity restrictions: [Relevant limitations such as keeping wound dry, avoiding friction, elevation]
• Return precautions: [Warning signs reviewed: uncontrolled bleeding, fever, spreading redness, worsening pain, purulent drainage, signs of allergic reaction]
• Follow-up: [Suture removal timing if applicable]; [Wound check or packing change appointment if applicable]; [Plan for communicating results and timeframe]; [Plan if results indicate need for further treatment]

(Safety-critical elements—allergies, anticoagulants, site laterality, time-out, consent, and specimen labeling—should never be left blank. Use explicit statements such as "denies," "none," or "not assessed." Omit entire optional sections that do not apply rather than documenting them as not applicable.)