Soft Tissue Excision/Biopsy Operative Note (Skin/Subcutaneous Mass)

Date: [Date]

Time: [Procedure time / Start time – End time if sedation used]

Location: [Clinic / Procedure room / Ambulatory surgery center / Hospital outpatient OR]

Surgeon: [Surgeon name and credentials]

Assistant(s): [Assistant name(s) and role(s) / None]

Procedure Summary

• Preoperative Diagnosis: [Diagnosis]
• Postoperative Diagnosis: [Diagnosis / Same]
• Procedure Performed: [Procedure name with laterality and anatomic site] (Do not infer laterality.)
• Indication: [One-line indication, e.g., diagnostic vs therapeutic intent] (Do not imply malignancy unless explicitly stated.)
• Anesthesia: [Local only / Local with oral anxiolysis / Moderate sedation]
• EBL: [Numeric mL / Minimal]
• Specimen(s): [Brief description with site, laterality, and disposition / None]
• Complications: [None / Description of complication]
• Disposition: [Home / Recovery area / Observation] in [stable / baseline] condition

Indications

[Clinical context paragraph, 2–5 sentences] (Include patient-reported lesion description and clinician assessment; symptoms such as pain, growth, irritation, bleeding, or recurrent infection; prior evaluation such as imaging or biopsy; and rationale for excision versus biopsy. Do not infer malignancy suspicion—state rule-out malignancy only if explicitly documented.)

Consent and Safety Checks

• Informed consent: [Obtained / Not obtained—document rationale and authority]
• Risks discussed: [Risks discussed, e.g., bleeding, infection, scarring, dehiscence, recurrence, nerve injury/numbness, poor cosmetic outcome, need for further surgery]
• Site marking: [Site identified and marked / Not applicable] (Required for laterality or multiple lesions.)
• Time-out: [Completed confirming patient identity, procedure, site/side, allergies, anticoagulant status / Exception documented: [reason]]

Anesthesia

• Local anesthetic: [Drug name and concentration] [with epinephrine [concentration] / without epinephrine]; [volume] mL via [local infiltration / field block / nerve block]
• Buffering: [Sodium bicarbonate added / Not performed]
• Topical anesthetic: [Drug and timing / None]
• Sedation: [None / Agent(s), dose(s), route, and responsible provider]

Preparation and Positioning

• Position: [Supine / Prone / Lateral / Sitting]
• Skin prep: [Chlorhexidine / Povidone-iodine / Alcohol-based] applied and allowed to dry
• Draping: [Sterile draping performed]
• Technique: [Sterile technique maintained]

Operative Findings

• [Lesion mobility: mobile / fixed / partially mobile]
• [Lesion character: well-circumscribed / ill-defined; cystic / solid / lipomatous; inflamed / non-inflamed]
• [Unexpected findings: purulence / foreign body / fascial involvement / adherence to neurovascular structures / None]

Procedure Details

(Document each lesion separately using the structure below. Repeat the "Lesion #" block for each treated lesion.)

Lesion #1

Lesion and Measurements

Location: [Exact anatomic location with laterality and landmarks] (Do not infer laterality.)

Lesion size: [Length] × [Width] cm (× [Depth] if relevant) (Measurements must be explicitly stated.)

Margins/Plane: [Planned clinical margins in mm / Dissection plane and capsule preservation for non-margin excisions]

Depth: [Dermis / Subcutaneous / Suprafascial / Subfascial / Intramuscular]

Incision and Dissection

[Incision type: elliptical / linear / fusiform] oriented [along relaxed skin tension lines / other orientation]. [Dissection method: sharp / blunt / combination] through [tissue planes]. Lesion removed [en bloc / piecemeal]. [Capsule intact / Capsule ruptured—describe management].

Hemostasis

[Method(s): direct pressure / electrocautery / ligation / topical agent [name]]. [Irrigation performed with [solution] / No irrigation].

Specimen Handling

• Specimen: [Exact label as on container/requisition]
• Source: [Anatomic site with laterality] (Never infer laterality.)
• Dimensions: [L × W × D in cm]
• Orientation: [Orientation method and key, e.g., "long suture marks lateral, short suture marks superior" or "12 o'clock inked blue" / Specimen not oriented] (Do not infer orientation.)
• Margins requested: [Evaluate peripheral and deep margins / Not applicable]
• Disposition: [Submitted to pathology in formalin / Sent fresh for culture / Not submitted—document reason]

Closure

Closure type: [Simple / Layered / Complex / Secondary intention / Packed]

• Deep layer: [Suture material and size; pattern / Not applicable]
• Deep dermal/subcuticular: [Suture material and size; pattern / Not applicable]
• Epidermal: [Suture material and size; simple interrupted / running / mattress / Skin adhesive / Adhesive strips]

Undermining: [Extent and rationale / None]

Final wound length: [Length] cm

Dressing

[Materials applied, e.g., petrolatum, topical antibiotic, nonadherent pad, gauze, tape, pressure dressing]

Lesion #2

(Include only if additional lesion treated; otherwise delete this section.)

Lesion and Measurements

Location: [Anatomic location with laterality]

Lesion size: [L × W (× D) cm]

Margins/Plane: [Margins in mm / Dissection plane]

Depth: [Tissue plane]

Incision and Dissection

[Incision and dissection details]

Hemostasis

[Hemostasis details]

Specimen Handling

• Specimen: [Exact label]
• Source: [Site with laterality]
• Dimensions: [L × W × D cm]
• Orientation: [Orientation details / Specimen not oriented]
• Margins requested: [Details]
• Disposition: [Details]

Closure

[Closure details]

Dressing

[Dressing details]

Counts

[Sponge, sharp, and instrument counts correct / Not applicable per facility policy / Discrepancy noted: [resolution]]

Complications and Tolerance

Intraoperative complications: [None / Description]

Condition at procedure end: [Stable, pain controlled, neurovascular status intact / Other findings]

Disposition and Follow-up

• Discharge to: [Home / Recovery area] in [stable / baseline] condition
• Suture removal: [Number] days / Not applicable
• Pathology results: Will be communicated via [phone / patient portal / follow-up visit]
• Wound care instructions: Written instructions provided
• Return precautions: [Precautions discussed, e.g., signs of infection, bleeding, dehiscence, uncontrolled pain, numbness/weakness]