Skin Biopsy Procedure Note (Incisional)

Date/Time of Procedure: [Date and time of procedure]

Location: [Clinic/OR setting and room if applicable]

Performing Clinician: [Name, credentials]

Procedure: [Incisional (wedge) biopsy of skin; exact anatomic site with laterality; depth; closure type; final closure length in cm] (Provide a single-line summary including procedure name, exact site with laterality, depth, closure type, and final closure length.)

Indication

[Clinical indication and working diagnosis; 2–3 differential diagnoses when appropriate; lesion description including location with laterality, measured size in cm, and key morphology; whether edge versus center was sampled if relevant; pertinent risk context if applicable such as immunosuppression, prior skin cancers, or factors affecting wound healing] (Concise narrative. Include only details explicitly assessed.)

Pre-Procedure

• Consent: [Patient demonstrated capacity; nature/purpose, risks (bleeding, infection, scarring, pain, dehiscence, nerve/vessel injury as site-appropriate), benefits, and alternatives discussed; questions addressed; informed consent obtained] (If not documented, insert [CONSENT NOT DOCUMENTED - MUST COMPLETE].)
• Safety Verification: [Two patient identifiers verified; site marked by proceduralist; time-out completed immediately prior to incision confirming patient, procedure, site/laterality, and specimen labeling plan] (If not documented, insert [TIME-OUT/SITE VERIFICATION NOT DOCUMENTED - MUST COMPLETE].)
• Allergies: [Relevant allergies to local anesthetics, adhesives, or topical antibiotics; or "no relevant allergies"] (Include only if assessed.)
• Anticoagulant/Antiplatelet Status: [Agent(s), last dose, peri-procedural plan; or "not on anticoagulants/antiplatelets"] (Include only if assessed and relevant.)

Anesthesia

• Agent and concentration: [Anesthetic agent and concentration, with or without epinephrine]
• Total volume: [Volume in mL]
• Technique: [Local infiltration / field block]
• Adequacy: [Adequate anesthesia confirmed prior to incision]

Technique

[Chronological narrative: patient position; skin prep agent; sterile technique; explicit incisional/wedge approach with instrument used and orientation relative to skin tension lines if noted; depth of biopsy stated explicitly (e.g., through dermis into subcutaneous fat); hemostasis method; unexpected operative findings if any; for high-risk locations (face, digit, ear), avoidance of critical structures and post-procedure neurovascular status as appropriate] (Do not infer depth or technique details. If depth not stated, include [DEPTH NOT DOCUMENTED].)

Specimen

(Repeat block for each specimen submitted.)

• Site: [Exact anatomic site with laterality] (Must match the procedure description.)
• Biopsy type: [Incisional / wedge]
• Dimensions: [Specimen dimensions in cm] (Include if measured.)
• Fixative/Transport medium: [Formalin / Michel's medium / saline / other] (Explicitly note if DIF specimen was NOT placed in formalin.)
• Orientation/Marking: [Orientation scheme with marking method (e.g., single suture marks superior); or "not oriented"] (If not documented, insert [SPECIMEN ORIENTATION NOT DOCUMENTED].)
• Labeling: [Specimen label identifiers and container count] (If not documented, insert [SPECIMEN LABELING NOT DOCUMENTED].)
• Pathology requisition: [Working diagnosis; relevant clinical history; special requests such as margins, special stains, DIF, or culture]

Closure

• Defect size: [Defect dimensions in cm]
• Closure complexity: [Simple / layered (intermediate) / complex] (Do not infer; document based on what was performed.)
• Undermining: [Extent and plane of undermining; or "none"] (Include if performed.)
• Deep layer: [Suture material, size, technique] (Include only if layered closure performed.)
• Epidermal layer: [Suture material, size, technique; or adhesive/strips if used]
• Final closure length: [Length in cm] (If closure details are missing, insert [CLOSURE DETAILS NOT DOCUMENTED].)
• Secondary intention: [Wound left open with rationale] (Include only if applicable.)

Post-Procedure

• Estimated blood loss: [Volume in mL or "minimal"] (Document explicitly; do not default.)
• Complications: [None; or description with intervention and outcome] (Document explicitly; do not default to none.)
• Patient tolerance/condition: [Tolerance of procedure; condition at completion (e.g., stable, ambulatory)]
• Dressing: [Topical agent and dressing type applied]

Aftercare & Follow-Up

• Instructions: [Written and verbal wound care instructions provided; patient verbalized understanding] (Do not include full instruction text in note.)
• Suture removal: [Location-appropriate timing in days] (Include if nonabsorbable sutures placed.)
• Pathology results plan: [Expected turnaround; method of communicating results to patient; contingency for malignant or nondiagnostic findings]
• Follow-up: [Scheduled return appointment or PRN instructions]