Skin Biopsy Procedure Note

A structured procedure note template for outpatient shave and punch skin biopsies. Features per-lesion documentation blocks, explicit safety verification fields (consent, time-out, site marking), and specimen tracking wi…

Document Type

clinical note / Procedure Note

Specialties

Osteopathic Doctor
Created by Augustun

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Date/Time of Procedure: [Date and time]

Location: [Clinic / procedure room / other specific location]

Operator: [Name, credentials]

Patient: [Name and DOB or MRN per local policy]

Procedure Summary

  • Procedure(s): [shave biopsy / punch biopsy / shave + punch] with [instrument details and punch size if applicable]
  • Lesions & Sites: [Number of lesions] at [anatomic sites with laterality]
  • Indication/Clinical Impression: [Clinical impression] (Pre- and post-procedure diagnoses are typically the same; do not upgrade diagnosis without pathology confirmation.)

Lesion Description

(Repeat this block for each lesion biopsied.)

Lesion [number]

Site: [Exact anatomic location with laterality and landmarks]

Size: [Size in mm] [measured / estimated]

Morphology: [macule / papule / plaque / nodule], [color], [border characteristics], [ulceration if present], [scale if present]

Pigmented Lesion Features: [ABCDE features, dermoscopy findings if performed] (Include only for pigmented lesions; omit this line otherwise.)

Symptoms/History: [Bleeding, pruritus, growth, change over time] (Include only if reported; omit this line if not reported.)

Pre-Procedure Assessment

(Include this section only if relevant risk modifiers are present; omit entirely if none.)

  • Allergies: [Relevant allergies to local anesthetics, latex, adhesives, antiseptics, or topical antibiotics]
  • Anticoagulation/Bleeding Risk: [Anticoagulant or antiplatelet medications, coagulopathy, or other bleeding risk factors]

Informed Consent

[Consent obtained / Consent not obtained with specific exception and justification]. Procedure explained including anticipated closure method. Risks discussed including bleeding, infection, scarring, dyspigmentation, poor wound healing, and [site-specific risks if applicable]. Alternatives reviewed. Questions answered. Patient verbalized understanding and agreement.

Interpreter: [Language and interpreter used] (Include only if interpreter was used; omit this line otherwise.)

Site Verification & Time-Out

  • Patient Identity: Confirmed with two identifiers
  • Site Verification: Correct [site / side / lesion] verified; [site marked / site marking not required]
  • Time-Out: Completed immediately prior to procedure

(If any safety step was not performed, document the specific reason.)

Preparation & Anesthesia

Positioning: [Patient positioning]

Skin Preparation: [Chlorhexidine / povidone-iodine / alcohol] with sterile technique

Anesthesia: [Agent and concentration], [buffered / unbuffered], [volume] mL via [local infiltration / field block / nerve block] (If no anesthesia used, state "None used" with brief rationale.)

Procedure Details

(Repeat this block for each lesion.)

Lesion [number]

Biopsy Type: [Shave / punch]

Instrument: [Dermablade / #15 blade / punch size in mm]

Technique & Depth: [Tangential shave / saucerization / full-thickness punch / partial-thickness punch] to [superficial dermis / mid-dermis / deep dermis / subcutaneous fat]

Hemostasis: [Pressure / aluminum chloride / electrocautery / ferric subsulfate / other]

Closure: [Healing by secondary intention / suture material, size, technique, number of sutures]

Dressing: [Dressing applied]

Estimated Blood Loss: [Volume] (Include only if more than minimal or required by local policy; omit otherwise.)

Specimen Handling

Number of Specimens: [Number]

  • Specimen [A/1]: [Source site] — [biopsy type] — [formalin / Michel's medium / other fixative] (Note orientation marking and meaning if applicable.)
  • (Add additional specimens as needed.)

Pathology Destination: [Internal dermatopathology / external laboratory name]

Clinical Information Sent: [Clinical impression, lesion duration, prior biopsy history if relevant]

Post-Procedure Status

Tolerance: [Tolerated procedure well / describe tolerance]

Complications: [No immediate complications / complication and management]

Disposition: [Discharged home / other disposition]

Neurovascular Status: [Findings] (Include only if assessed and relevant to the site; omit otherwise.)

Wound Care & Follow-Up

Wound Care Instructions: [Verbal / written handout / both] provided

Pathology Results: Results to be communicated via [method] within [timeframe]

Suture Removal: [Timing] at [location] (Include only if sutures placed; omit otherwise.)

Signature

[Electronic signature: Name, credentials, date/time]

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