Mohs Micrographic Surgery Operative Note

Date of Service: [date]  |  Facility: [facility name]  |  Patient: [full name, DOB, MRN]  |  Mohs Surgeon: [name, credentials]  |  Laterality and Anatomic Site: [right / left / midline] [anatomic site with landmarks]

Operative Summary

Pre-operative diagnosis: [biopsy-proven diagnosis]
Post-operative diagnosis: [final diagnosis]
Procedure: Mohs micrographic surgery, [anatomic site], [#] stage(s), margins [clear / residual tumor]
Final defect size: [L] × [W] cm
Reconstruction: [method / not repaired by Mohs surgeon—disposition noted]
Complications: [none / description]
Disposition: [stable, tolerated procedure well / other]

Indication and Medical Necessity

Biopsy-proven diagnosis: [diagnosis]  |  Histologic subtype: [subtype / not specified]  |  Biopsy date: [date / biopsy date needed]  |  Accession #: [number / not accessible]

• Risk/complexity features supporting Mohs: [high-risk anatomic location / size criteria / ill-defined borders / recurrent tumor or prior treatment failure / aggressive histology / perineural invasion concern / immunosuppression / other host factors] (Select all applicable factors; avoid generic boilerplate.)
• Alternatives considered and rationale not chosen: [standard excision / curettage and destruction / radiation / topical therapy / observation] — [specific rationale pertinent to this case]
• Tissue preservation or same-day margin control considerations: [explanation / not applicable]

(This section must always be present for billing compliance; include explicit placeholders when information is missing.)

Pre-Procedure Verification

• Identity, site, and procedure verification: [completed with patient and chart cross-check]
• Site marking: [marked with surgical marker / not applicable—reason]
• Time-out: [completed] confirming patient, procedure, site, and laterality
• Informed consent: [obtained for Mohs surgery including risks, benefits, and alternatives; repair consent obtained if planned by same surgeon]
• Safety considerations: Allergies [none / list]; Anticoagulant/antiplatelet status [none / agent—perioperative plan]; Implanted cardiac device [none / pacemaker / ICD—precautions addressed]; Prophylaxis [not indicated / indicated—agent and rationale]

Anesthesia and Preparation

• Anesthesia type: [local infiltration / field block / nerve block / tumescent]
• Local anesthetic: [agent, concentration, total volume administered] (Note buffering or additional injections per stage if applicable.)
• Skin preparation: [chlorhexidine / povidone-iodine / alcohol] to operative field
• Hemostasis techniques: [electrocautery / aluminum chloride / pressure / suture ligation / other]

Mohs Technique Attestation

Mohs micrographic surgery was performed using accepted technique with staged excision, tissue orientation, mapping, processing, and intraoperative microscopic examination of 100% of peripheral and deep margins. The Mohs surgeon personally examined and interpreted all Mohs histology for this case.

Case/Lesion 1

Laterality and Anatomic Site: [right / left / midline] [anatomic site with landmarks]

Pre-Mohs Lesion Description

• Clinical size (pre-excision): [L] × [W] cm
• Border delineation method: [curettage / dermoscopy / Wood's lamp / skin stretched / clinical margins]
• Clinical appearance: [papule / plaque / nodule / ulcer / scar]; [pigmented / non-pigmented]; [indurated / non-indurated]
• Photo documentation: [pre-op photos obtained and stored in chart / not performed—reason]

Stage-by-Stage Excision and Histology

(Document each stage. Use block counts, not slides. Include map orientation and storage location. Use clock-face positions and block labels for positive margins.)

Stage 1

• Number of tissue blocks: [#]
• Orientation and map reference: Mohs map completed, stored in [scanned media / imaging tab / appended to note]
• Histology: Depth of invasion [epidermis / dermis / subcutis]; Pattern/subtype [nodular / infiltrative / morpheaform / other]; Perineural invasion [present / absent]; Scar tissue [present / absent] (If no residual tumor in Stage 1, state explicitly: "No residual tumor identified.")
• Tumor present: [yes / no]
• Margin status: [positive / negative]
• Location of positive margins: [clock-face position(s) and block label(s) / not applicable—margins clear]

Stage 2 (Include only if additional stages performed.)

• Number of tissue blocks: [#]
• Orientation and map reference: Mohs map updated, stored as above
• Histology: [as in Stage 1 / describe differences]
• Tumor present: [yes / no]
• Margin status: [positive / negative]
• Location of positive margins: [clock-face position(s) and block label(s) / not applicable—margins clear]

(Add additional stages as needed until margins are clear.)

Debulk specimen / Special studies: [Debulk specimen in container labeled [label] sent to [pathology lab]; Stains/IHC: [type]; Results: [summary] / not applicable]

Final Defect and Margin Status

• Margins cleared at: Stage [#]
• Final margin status: Clear at Stage [#]
• Final defect size: [L] × [W] cm
• Depth/structures exposed: [dermis / subcutis / perichondrium / cartilage / muscle / periosteum / bone]
• Hemostasis: [achieved / additional measures: description]

Reconstruction

Rationale for repair type: [functional / cosmetic / tissue preservation / contour / other]

Secondary intention: Wound left to granulate. Dressing applied: [type]. Anticipated course: [description].

Primary linear closure: Undermining [yes—plane / no]. Layered closure [yes / no]. Final closure length: [#] cm. Sutures: deep [type, size]; superficial [type, size].

Flap: Type/design: [flap name]. Dimensions: [#] × [#] cm. Undermining plane: [plane]. Pedicle management: [details]. Sutures: deep [type, size]; superficial [type, size].

Graft: Type: [full-thickness / split-thickness]. Size: [#] × [#] cm. Donor site: [location]; closure: [method]. Bolster/dressing: [details].

Combination repair: [Specify which portion closed by which method.]

Not repaired by Mohs surgeon: Defect to be repaired by [specialty or surgeon name], [same day / scheduled for later date]. Interim dressing: [type]. Handoff communication: [completed with receiving service].

(Select and complete the applicable repair type; delete others.)

Case/Lesion 2

(If multiple lesions were treated, duplicate the Case/Lesion 1 structure above for each additional lesion. Renumber sequentially.)

Operative Completion

• Estimated blood loss: [minimal / volume in mL]
• Complications and management: [none / description]
• Specimens summary: Mohs tissue processed per stages above; [additional specimen(s) to outside pathology / none]
• Patient condition at conclusion: [stable, tolerated procedure well / other]

Post-Procedure Care

• Dressing applied: [type; pressure dressing or bolster if applicable]
• Wound care instructions: [provided verbally and in writing]
• Pain management: [first-line analgesic and dosing instructions]
• Antibiotics: [agent, dose, duration, indication / not prescribed]
• Activity restrictions: [restrictions and duration]
• Follow-up plan: Wound check [date]; Suture removal [date / not applicable]; [coordination with other service if referred for repair]

(If any required information is not provided in dictation, retain the section with explicit placeholders such as "[biopsy date needed]" rather than omitting. The Indication and Medical Necessity section and Stage-by-Stage Excision and Histology section must always be present for billing compliance.)