Dermal Electrosurgical Shave Excision - May 1, 2002 - American Academy of Family Physicians

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Procedure Recording Form

Dermal Electrosurgical Shave Excision

Patient name: ______________________________ Date: __________ Age: ______

Lesion 1

Location: _________________________________________________________

Symptoms: _________________________________________________________

Clinical impression: _________________________________________________________

Sent for histology?	Yes	No	Irritation from clothing or jewelry?	Yes	No
Bleeding?	Yes	No	Pain or tenderness?	Yes	No
Inflamed?	Yes	No

Lesion 2

Location: _________________________________________________________

Symptoms: _________________________________________________________

Clinical impression: _________________________________________________________

Sent for histology?	Yes	No	Irritation from clothing or jewelry?	Yes	No
Bleeding?	Yes	No	Pain or tenderness?	Yes	No
Inflamed?	Yes	No

Lesion 3

Location: _________________________________________________________

Symptoms: _________________________________________________________

Clinical impression: _________________________________________________________

Sent for histology?	Yes	No	Irritation from clothing or jewelry?	Yes	No
Bleeding?	Yes	No	Pain or tenderness?	Yes	No
Inflamed?	Yes	No

Other lesions: _________________________________________________________

Procedure description:

The patient gave informed consent for the procedure. Other options were discussed, and the patient elected to undergo the electrosurgical shave excision. The lesion and surrounding skin were prepped with povidone-iodine solution and anesthetized with 2 percent lidocaine (with epinephrine) using a 30-gauge needle. The patient tolerated the anesthesia well. Sharp excision was carried out using a no. 15 blade held horizontal to the skin surface. Monsel's solution was applied with a cotton-tipped applicator to the wound base for hemostasis. Electrosurgical feathering was carried out using a cutting current and a setting of 1.5 to 3.0 (15 to 30 W). The wound edges were gently blended into the surrounding skin to improve the final scar result. Monsel's solution again was applied for hemostasis, and antibiotic ointment and a bandage were placed over the wound.

Complications: _________________________________________________________

Plan:
_____	Patient will be notified of the histology results.
_____	Patient was asked to be patient as the scar matures over time.
_____	Patient will return if excessive scar or lesion recurrence are noted.
_____	Patient was informed to return if the lesion appears infected.
_____	Postprocedure instruction sheet was given to patient.

Physician: ____________________________ CC: ____________________________

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

Copyright © 2002 by the American Academy of Family Physicians.
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