Skin Biopsy Procedure Note (Punch)

Date/Time of Procedure: [Date and time]

Location: [Clinic/procedure room]

Operator: [Name and credentials]

Assistant: [Name and role, or "none"]

Patient Position: [supine / prone / lateral decubitus (left/right) / seated]

Indication

[Indication for biopsy in one sentence stating the diagnostic question]

Provisional diagnosis/differential: [1–5 items]

Lesion description: [Exact anatomic site with landmarks and laterality — REQUIRED], [morphology], [approximate size]

[Reason punch technique selected] (Only include if relevant to clinical question or technique.)

(Exclude extended HPI/ROS unless directly affecting technique, e.g., anticoagulation or bleeding disorder.)

Pre-Procedure

• Patient identification: Two identifiers verified
• Site verification/marking: [marked / not required / not feasible — reason]
• Time-out: [Performed with team members / Single-clinician attestation per policy]
• Informed consent: Obtained from [patient / guardian / POA]; [written and verbal / verbal only]. Procedure, indications, and material risks reviewed (bleeding, infection, scarring, pigment change, poor healing, allergic reaction, possible need for additional procedures); alternatives discussed; questions answered.

Procedure Details

Preparation

• Skin prep: [chlorhexidine / povidone-iodine / alcohol / other]
• Technique level: [clean / sterile] field; [clean / sterile] gloves; drape [yes / no]
• Anesthesia: [Agent and concentration], [volume in mL], [route]; allergy check completed

Biopsy

Technique summary: [Brief technique description, e.g., perpendicular approach with rotational advancement; specimen retrieved with forceps and iris scissors] (If technique varies by site, document within each specimen block instead.)

Specimen A:

• Site and laterality: [Exact anatomic site with landmarks and laterality — REQUIRED]
• Targeted area: [center / edge / perilesional for DIF / other]
• Punch size: [mm — REQUIRED]
• Depth achieved: [mid-dermis / full-thickness dermis / into subcutis / other]
• [Orientation marking if clinically important] (Omit if not applicable.)

Specimen B: (Include only if applicable.)

• Site and laterality: [Exact anatomic site with landmarks and laterality — REQUIRED]
• Targeted area: [center / edge / perilesional for DIF / other]
• Punch size: [mm — REQUIRED]
• Depth achieved: [mid-dermis / full-thickness dermis / into subcutis / other]
• [Orientation marking if clinically important] (Omit if not applicable.)

Specimen C: (Include only if applicable.)

• Site and laterality: [Exact anatomic site with landmarks and laterality — REQUIRED]
• Targeted area: [center / edge / perilesional for DIF / other]
• Punch size: [mm — REQUIRED]
• Depth achieved: [mid-dermis / full-thickness dermis / into subcutis / other]
• [Orientation marking if clinically important] (Omit if not applicable.)

Hemostasis

• Method(s): [direct pressure / aluminum chloride / electrocautery / suture ligation / combination]
• Estimated blood loss: [mL]

Closure

[No closure; healing by secondary intention] OR [Closure performed: [simple interrupted / vertical mattress / horizontal mattress / running / adhesive strips / tissue adhesive], [suture type and size], [number of sutures], removal in [days] at [location]]

Dressing

• Topical: [petroleum jelly / antibiotic ointment — reason if used]
• Dressing: [non-adherent gauze with tape / occlusive / other]

Specimen Handling

(Specimen labels must match Specimen A/B/C blocks above for clear specimen-to-site mapping.)

Specimen A:

• Container and medium: [formalin / Michel's medium / sterile container for culture / other — REQUIRED]
• Labeling: Two patient identifiers + specimen site confirmed on container
• Destination lab: [Lab name]
• Studies ordered: [H&E / DIF / special stains / culture / other]

Specimen B: (Include only if applicable.)

• Container and medium: [formalin / Michel's medium / sterile container for culture / other — REQUIRED]
• Labeling: Two patient identifiers + specimen site confirmed on container
• Destination lab: [Lab name]
• Studies ordered: [H&E / DIF / special stains / culture / other]

Specimen C: (Include only if applicable.)

• Container and medium: [formalin / Michel's medium / sterile container for culture / other — REQUIRED]
• Labeling: Two patient identifiers + specimen site confirmed on container
• Destination lab: [Lab name]
• Studies ordered: [H&E / DIF / special stains / culture / other]

Patient Tolerance and Complications

• Tolerance: [well / poorly]
• Immediate complications: [none / specify event and management]
• Post-procedure condition: [stable / other]

Follow-Up Plan

• Wound care instructions provided: Keep dressing dry 24 hours; then daily cleansing with soap and water; apply petroleum jelly and clean dressing until healed; avoid soaking; apply firm direct pressure 10 minutes if bleeding occurs.
• Activity restrictions: [none / avoid strenuous activity or tension at site / site-specific precautions]
• Suture removal: [timeframe in days] at [location] (Omit if no sutures placed.)
• Pathology results: Expected in [timeframe]; patient to be contacted via [phone / portal / other]. Patient instructed to call if not contacted by [date]. [Expedited follow-up plan if high suspicion for malignancy] (Include if applicable.)

(If site/laterality, punch size, or specimen medium cannot be documented at time of procedure, enter "NOT DOCUMENTED — REQUIRES COMPLETION" and resolve before finalizing note.)