Skin Biopsy Procedure Note (Tangential/Shave)

Procedure: Tangential (shave) biopsy of skin

Date: [Date]

Clinician: [Clinician name, credentials]

Number of lesions biopsied: [Number]

Indication

(For a single lesion, use one concise paragraph. For multiple lesions, use a labeled list as shown below. If melanoma is suspected, explicitly document suspicion, rationale for tangential approach, and intended depth.)

• Lesion A: [Anatomic site with laterality and specific subsite] | [Lesion size in cm] | [Brief clinical description] | [Clinical impression or rule-out diagnosis] | [Dermoscopy findings, if mentioned] | [Melanoma suspicion statement and rationale, if applicable]
• Lesion B: [Anatomic site with laterality and specific subsite] | [Lesion size in cm] | [Brief clinical description] | [Clinical impression or rule-out diagnosis] | [Dermoscopy findings, if mentioned] | [Melanoma suspicion statement and rationale, if applicable]

(Anatomic site with laterality and lesion size are required for each lesion. Do not infer—insert placeholder if missing.)

Pre-Procedure

Time-out: [Completed immediately prior to procedure, confirming patient identity, procedure, and site with laterality]

Consent: [Informed consent obtained; risks (bleeding, infection, scarring, need for additional procedure, nondiagnostic result) and alternatives discussed; patient agreed to proceed]

Relevant risk factors: [Allergies to anesthetics/antiseptics] | [Anticoagulant/antiplatelet use] | [Bleeding history] | [Keloid tendency] (Document "unknown" if not assessed rather than omitting.)

Patient position: [Position]

Skin preparation: [Preparation agent] | [Clean / sterile technique]

Anesthesia: [Medication name] | [Concentration] | [Epinephrine ratio, if used] | [Total volume in mL] | [Route: local infiltration / field block] (For multiple lesions, specify allocation per lesion. Do not infer anesthetic details—document only what was administered.)

Procedure

(Document each lesion separately. Use brief 1–3 sentence narrative per lesion. If technique is identical across all lesions, document once and reference each lesion.)

• Lesion A: [Site, must match Indication]

  Technique: [Shave / scoop / saucerization / curette] using [instrument]

  Depth: [Epidermis and superficial dermis / deep saucerization] (Include if assessed.)

  Hemostasis: [Method: aluminum chloride / electrodessication / direct pressure / other]; hemostasis achieved

  Wound care: [Topical applied] | [Dressing type] | Healing by secondary intention

• Lesion B: [Site, must match Indication]

  Technique: [Shave / scoop / saucerization / curette] using [instrument]

  Depth: [Epidermis and superficial dermis / deep saucerization] (Include if assessed.)

  Hemostasis: [Method]; hemostasis achieved

  Wound care: [Topical applied] | [Dressing type] | Healing by secondary intention

Patient tolerance: [Tolerated well / description]

Complications: [None / description with immediate management]

Estimated blood loss: [Volume in mL] (Only include if more than minimal.)

Specimen

(Explicitly map each specimen to its corresponding lesion. Ensure identifiers match those used above.)

• Specimen A: Lesion A | [Anatomic site and laterality on label] | [Container/fixative] | Sent to pathology | [Clinical impression on requisition]
• Specimen B: Lesion B | [Anatomic site and laterality on label] | [Container/fixative] | Sent to pathology | [Clinical impression on requisition]

Follow-Up

Wound care instructions: [Dressing care, cleaning frequency, topical application, activity restrictions]

Bleeding precautions: [Apply direct pressure for specified duration if bleeding occurs; when to seek care for persistent bleeding]

Infection precautions: [Return if increasing pain, redness, warmth, purulent drainage, or fever]

Pathology results plan: [Communication method] | [Expected timeframe] | [Follow-up plan if further treatment needed]

[Patient received instructions and confirmed understanding]