Wound Biopsy Procedure Note

Date and time of procedure: [Procedure date and time]

Procedure location/setting: [Outpatient clinic / Operating room / Bedside (unit/room) / Other: specify]

Operator: [Operator full name, degree(s), and role]

Procedure performed: [Punch biopsy / Shave biopsy / Incisional biopsy / Excisional biopsy] (List all techniques if more than one used.)

Indication and Clinical Context

[Narrative establishing medical necessity] (3–6 sentences. Include: reason for biopsy such as atypical appearance or non-healing despite appropriate care; duration and trajectory of the wound; summary of prior wound management and response; pertinent risk factors such as vascular disease, diabetes, immunosuppression, prior radiation, or chronic scar; and clinical differential diagnosis with 2–5 items. If prior biopsies exist, include date and result if known. Do not infer treatment response—document only what is known or state that history is limited.)

Pre-Procedure Safety

Informed consent: [Written / Verbal] consent obtained from [patient / surrogate (state relationship)]. Risks discussed including bleeding, infection, pain, scarring, delayed healing, and possible need for additional procedures. Alternatives and opportunity for questions addressed. (Never infer consent; explicitly document.)

Allergies: [Relevant allergies to local anesthetics, antiseptics, or adhesives / No known relevant allergies]

Anticoagulant/antiplatelet use: [None / Agent(s) with peri-procedural management plan]

Pre-procedure verification and time-out: Patient identity verified with two identifiers. Correct procedure confirmed: [procedure]. Correct site and laterality confirmed: [site and laterality]. Site marked: [Yes / No / Not applicable]. Time-out performed immediately prior to the procedure.

Wound Description

Anatomic location: [Exact location with laterality and reproducible landmark, e.g., distance from fixed anatomic point]

Measurements: [Length] × [Width] cm; depth [value in cm / unable to assess due to (reason)]. Undermining/tunneling: [None / Clock-face position(s) and extent]

Morphology: [Edge character], [base appearance], [exudate/odor if notable], [surrounding skin findings], [friability], [pain characteristics]

Photo documentation: [Storage location/system] (Include only if photos obtained.)

Procedure Details

Pre-procedure diagnosis: [Diagnosis or clinical impression]

Post-procedure diagnosis: [Same, pending pathology / Updated diagnosis]

Skin preparation: [Antiseptic agent]; sterile technique maintained.

Local anesthesia: [Agent and concentration], epinephrine [Yes / No], [local infiltration / field block], [total volume] mL. (If none used, state "None" and explain why.)

[Narrative description of the procedure] (Describe technique used, target area within the wound with clock-face or landmark reference, and number of specimens obtained.)

• Punch biopsy: [Size in mm], depth to [dermis / subcutis / fascia], sampling [wound edge with adjacent normal skin / base / both]. (Include only if punch performed.)
• Shave biopsy: [Epidermal / Dermal / Saucerization] depth, [location relative to wound]. (Include only if shave performed.)
• Incisional biopsy: [Dimensions in cm], edge with adjacent normal skin sampled [Yes / No], base sampled [Yes / No]. (Include only if incisional performed.)
• Excisional biopsy: Ellipse [dimensions in cm], margin [width if applicable]. (Include only if excisional performed.)

Hemostasis: [Pressure / Chemical agent (specify) / Cautery / Suture]; adequate hemostasis achieved [Yes / No, describe additional measures].

Specimen Handling

(List each specimen container separately.)

• Specimen A: [Source with laterality and clock-face/landmark], [biopsy type and size], [destination test: histopathology / culture / direct immunofluorescence / other], [fixative/medium]
• Specimen B: [Source], [biopsy type and size], [destination test], [fixative/medium] (Add additional specimens as needed.)

Specimen containers labeled at bedside with two patient identifiers, specimen source/site with laterality, and collection date/time.

Pathology requisition includes: [Wound duration, clinical appearance, suspected etiology, relevant comorbidities, prior treatments, differential diagnosis or specific diagnostic question]

Closure and Dressing

Estimated blood loss: [Minimal / Value if quantified]

Closure: [None (secondary intention) / Sutures: (material, size, technique, number; removal planned in X days) / Adhesive strips / Skin glue]

Dressing: [Type and layers applied]. [Special instructions: continue compression / offloading / other wound care modifications]

Post-Procedure Status

Patient tolerance: [Well tolerated / Tolerated with discomfort / Other]

Neurovascular status: [Intact distally / Findings] (Include for distal extremity procedures.)

Complications: [None / Describe]

Disposition: [Home / Returned to unit / Other]

Follow-Up Plan

Wound care instructions: [Printed handout / Verbal] provided, including dressing changes, cleansing, activity restrictions, expected symptoms, and red flags (uncontrolled bleeding, spreading erythema, fever, worsening pain, purulent drainage).

Pathology follow-up: Responsible reviewer: [Name or role]. Results communicated via [phone / patient portal / visit] within [expected timeframe]. Expedited contact plan for urgent findings: [Describe].

Wound care follow-up: [Next dressing change/wound check], [return visit timing], [suture removal date if applicable], [pending referrals]. (If not yet scheduled, document task-based plan.)