Skin Lesion Procedure Note (Biopsy, Excision, or Cryotherapy)

Date/Time of Procedure: [Date and time]

Clinician: [Operator name and credentials]

Patient Name: [Full name]

Patient Identifier: [MRN or DOB]

Procedure Summary: [One-line summary: procedure type(s), anatomic site(s) with laterality, number of lesions, specimen disposition]

Indication

[Clinical reason for procedure and pre-procedure diagnosis or clinical impression] (State indication clearly—e.g., suspicious lesion for histopathologic diagnosis, treatment of actinic keratoses. Include symptoms establishing medical necessity if present such as bleeding, rapid growth, or nonhealing. If diagnosis is uncertain, state that biopsy is for histopathologic diagnosis. Do not leave blank or infer from procedure performed.)

Lesion Description

(Use consistent numbering—Lesion 1, Lesion 2, etc.—matching specimen container labels when applicable. Do not omit laterality or size for biopsy or excision. If size not measured, state reason and label estimate clearly.)

Lesion #	Anatomic Site	Morphology	Size (mm)	Clinical Differential	Procedure
[Lesion 1]	[Site with laterality and landmarks]	[Papule / Plaque / Macule / Nodule / Patch / Other]	[Length × Width, measured / estimated]	[Clinical differential or notes]	[Biopsy / Excision / Cryotherapy]
[Lesion 2]	[Site with laterality and landmarks]	[Papule / Plaque / Macule / Nodule / Patch / Other]	[Length × Width, measured / estimated]	[Clinical differential or notes]	[Biopsy / Excision / Cryotherapy]

Pre-Procedure

Allergies Reviewed: [NKDA / List relevant allergies to anesthetics, adhesives, or antiseptics]

Bleeding Risk: [Anticoagulant/antiplatelet use, bleeding history, whether medications continued and rationale]

Informed Consent: [Verbal / Written] consent obtained. Nature, purpose, material risks, benefits, and alternatives including observation were discussed; questions answered; patient agreed to proceed. (For biopsy/excision: bleeding, infection, scarring, incomplete removal, need for further procedures. For cryotherapy: pain, blistering, pigmentary changes, incomplete clearance. Consent must be explicitly documented, never inferred.)

Site Marking: [Performed / Not performed—state reason if not performed]

Time-Out: Time-out performed confirming correct patient, procedure, site, and laterality. Participants: [Operator and additional participant(s)].

Anesthesia

[No anesthesia required / Local infiltration / Field block / Topical]

(If anesthesia used, include the following:)

Agent: [Agent and concentration]

Volume: [Total mL administered]

Procedure Details

(Organize by lesion number matching the Lesion Description. Include only the subsections for procedure type(s) performed. Do not infer technique parameters, closure type, or specimen details.)

Lesion 1

• Biopsy (if performed)
  • Type: [Shave / Punch (size in mm) / Incisional / Excisional]
  • Depth: [e.g., superficial dermis / mid-dermis / to subcutis]
  • Hemostasis: [Pressure / Aluminum chloride / Electrocautery / Other]
  • Wound management: [No closure / Adhesive strips / Suture closure (specify)]
  • Dressing: [Dressing type applied]
• Excision (if performed)
  • Pre-excision lesion size: [Length × Width in mm]
  • Planned clinical margins: [mm]
  • Excision depth: [e.g., to subcutaneous fat]
  • Specimen orientation: [Orientation method if used]
  • Hemostasis: [Method]
  • Closure: [Layers, suture material/size, and technique for each layer]
  • Final wound length: [cm]
  • Dressing: [Dressing type applied]
• Cryotherapy (if performed)
  • Technique: [Spray / Dipstick / Probe]
  • Freeze-thaw cycles: [Number]
  • Freeze time/endpoint: [Seconds per cycle or endpoint such as 1–2 mm ice halo]
  • Tissue response: [Immediate response observed]

Lesion 2

(Repeat structure for each additional lesion.)

Grouped Cryotherapy: (Optional—use when multiple similar lesions treated with identical parameters.) [Total lesion count, all anatomic sites, technique, cycles, freeze time/endpoint, tissue response]

Specimen and Pathology

(Include only when tissue is sent to pathology. Omit entirely for cryotherapy-only encounters.)

• Specimens: [Number of containers]
• Container 1: [Lesion # and anatomic site], [Formalin / Michel's medium / Other], [Special handling if any]
• Container 2: [Lesion # and anatomic site], [Formalin / Michel's medium / Other], [Special handling if any]
• Labeling: Containers labeled at bedside and verified.
• Results communication: [Method and expected timeframe]
• Contingency plan: [Plan for malignant findings or positive margins if clinically relevant]

Post-Procedure

Hemostasis: [Achieved / Describe management if not achieved]

Complications: [None / Describe complication(s) and management]

Patient Tolerance: [Tolerated well / Tolerated with difficulty / Other]

Follow-Up Plan

• Suture removal: [Date and location] (If applicable.)
• Return precautions: [Signs of infection, bleeding, expanding erythema, fever]
• Cryotherapy follow-up: [Expected healing time and when to return if lesions persist] (If applicable.)

Attestation

[Operator signature and credentials]