Patient name: ______________________________  Date: __________   Age: ______

Medications: _________________________________________________________

Lesion 1

Site: _______________________________  Drawing of the site:

Indication:

Clinical impression: ______________________________

Punch biopsy instrument: ______ mm

Suture closure: ______ -0 nylon

Lesion 2

Site: _______________________________  Drawing of the site:

Indication:

Clinical impression: ______________________________

Punch biopsy instrument: ______ mm

Suture closure: ______ -0 nylon

Lesion 3

Site: _______________________________  Drawing of the site:

Indication:

Clinical impression: ______________________________

Punch biopsy instrument: ______ mm

Suture closure: ______ -0 nylon

Procedure description:
The patient gave informed consent for the procedure. The biopsy site was selected, the skin was cleansed with povidone-iodine solution and the area was anesthetized with 2 percent lidocaine with epinephrine using a 30-gauge needle. The desired size punch biopsy instrument was selected, and the instrument was held vertically over the skin. The instrument was rotated downward until the entire skin thickness was penetrated. The punch biopsy instrument was removed, and the cylinder of skin was elevated using the anesthesia needle. Iris scissors were used to cut free the skin specimen from the subcutaneous tissue. The specimen was placed in formalin, and the site was closed using nylon suture. Good hemostasis was observed. Antibiotic ointment was placed over the wound, and a bandage was applied.

Complications: _________________________________________________________

Plan: Suture removal in ______ days.

Patient to be notified of the pathology results.

Wound instructions given.

Postprocedure instruction sheet given to patient.

Physician: ____________________________  CC: ____________________________

Adapted with permission from Zuber TJ. Office Procedures. Baltimore: Lippincott Williams & Wilkins, 1999.