Skin Cancer Excision & Reconstruction Operative Note

Patient: [Full name], MRN: [Medical record number]

Date of Birth: [DOB]

Date of Procedure: [Procedure date]

Start Time / Stop Time: [Start time] / [Stop time]

Location: [Clinic procedure room / ASC / OR] – [Facility name]

Surgeon: [Surgeon name, credentials]

Assistant(s): [Assistant name(s), credentials] (Include only if applicable)

Anesthesia Provider: [Name, credentials] (Include only if applicable)

Pre-Procedure Verification

(Include this section only if a formal time-out was performed per facility policy; omit entirely for office-based local procedures where not required.)

Informed consent was obtained covering excision, reconstruction options, and risks including bleeding, infection, scarring, dehiscence, flap/graft failure, and need for revision. [Site marking and time-out details confirming correct patient, procedure, site, and laterality]

Antibiotic Prophylaxis: [Agent, dose, timing] (Include only if administered)

Preoperative Diagnosis

[Diagnosis at time of surgery] (State the most specific diagnosis known; if biopsy-proven, note explicitly; if unconfirmed, use phrasing such as "suspicious lesion, rule out [condition]")

Postoperative Diagnosis

[Postoperative diagnosis] (Usually same as preoperative; update only if intraoperative findings changed the diagnosis)

Procedure(s) Performed

• [Procedure 1 with laterality and anatomic subunit]
• [Procedure 2 with laterality and anatomic subunit] (Include only if applicable)

Anesthesia

Type: [Local / field block / regional block / MAC / general]

(If surgeon-administered local anesthesia, include the following:)

Agent(s): [Agent with concentration, epinephrine if used, buffer if used]

Volume: [Total volume in mL] (Do not estimate; omit if not explicitly documented)

Technique: [Injection technique]

Indications

[Brief rationale for surgery and reconstruction approach] (2–4 sentences summarizing indication for surgery, relevant prior pathology including biopsy date and result if known, and justification for reconstruction choice based on tension, functional preservation, and anatomic subunit principles)

Lesion and Excision Details

(Include this section only if excision is performed by the documenting surgeon. Omit entirely for reconstruction-only/post-Mohs cases.)

Lesion 1

• Lesion Site: [Laterality and specific anatomic subunit]
• Lesion Size: [Greatest clinical diameter pre-excision in mm or cm]
• Planned Peripheral Margin: [Clinical margin width]
• Deep Margin Level: [e.g., to subcutaneous fat / to perichondrium / to periosteum]
• Excised Diameter: [Lesion diameter plus margins, measured clinically prior to excision]

(Duplicate as Lesion 2, Lesion 3, etc., for multi-lesion cases)

Defect

Defect 1

• Size: [REQUIRED: Length × width in cm]
• Depth: [Dermis / subcutaneous fat / perichondrium / cartilage / periosteum]
• Anatomic Units Involved: [List subunits if defect spans multiple]
• Exposed Structures: [Cartilage, bone, or other deep structures if present]

(For reconstruction-only cases, document defect as received, e.g., "Post-Mohs defect measuring [L × W] cm, depth to [tissue level]")

(Duplicate as Defect 2, Defect 3, etc., for multi-lesion cases)

Findings

[Lesion location confirmed; defect characteristics; tissue quality including laxity, prior scarring, or radiation changes if relevant; hemostasis status]

Procedure Details

(Compose as 1–3 chronological paragraphs covering only applicable elements below)

[Preparation and draping; anesthesia administration]

[Excision technique: incision, specimen removal, orientation method] (Include only if excision performed by documenting surgeon)

Primary Closure

(Include only if performed)

[Undermining plane and extent; hemostasis method; layered closure technique with suture materials by layer; final linear closure length in cm]

Local Flap (Adjacent Tissue Transfer)

(Include only if performed)

[Flap type and name (e.g., advancement, rotation, transposition—bilobed, rhombic, nasolabial); rationale for selection; design details including incision pattern, back-cuts, Burow triangles if used; elevation plane (subcutaneous / sub-SMAS / subperiosteal); inset technique; closure by layer with suture materials; viability statement including perfusion, capillary refill, and tension assessment]

Measurements: Primary defect [size in cm²], secondary defect [size in cm²], final closure length [cm]

Skin Graft

(Include only if performed)

[Graft type (split-thickness / full-thickness / composite); recipient site preparation and hemostasis; donor site location and harvest method; graft preparation (defatting for FTSG, meshing ratio for STSG if used); fixation technique (sutures, staples, quilting, bolster/tie-over); final assessment of graft seating and perfusion]

Measurements: Recipient defect [size in cm²], graft [size], donor site closure [method]

[Dressing application]

[Completion statement]

Specimen(s)

[REQUIRED: Either list specimens below or state "No specimen submitted; margins cleared by Mohs micrographic surgery"]

• Specimen A: [Site with laterality], [tissue type], oriented with [suture/ink marking method], submitted for [permanent pathology / frozen section]
• Specimen B: [Details as above] (Include only if applicable)

(Map specimen labels to corresponding lesion/defect for multi-lesion cases)

Materials

(Include only if applicable; omit section if none used unless local policy requires explicit documentation)

• Hemostatic Agents: [Agent(s) used]
• Biologics/Implants: [Material(s) used]
• Dressing: [Dressing type]

Estimated Blood Loss

[Numeric value in mL / minimal]

Complications

[None apparent / list complications]

Counts

(Include for OR/ASC cases; omit for office-based procedures where counts are not performed)

Sponge, needle, and instrument counts correct × 2.

Disposition

Condition: [Stable / other]

Destination: [REQUIRED: PACU / phase II recovery / discharged home / other]

Escort: [Name/relationship] (Include only if required for discharge)

Postoperative Plan

• Wound Care: [Dressing changes, bolster removal timing if applicable, ointment regimen]
• Activity: [Restrictions]
• Pain Management: [Plan]
• Antibiotics: [Prescription if given]
• Follow-up: [Timing for suture removal and wound check]
• Pathology: [Plan for communicating results; contingency if margins positive]