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DEPARTMENT OF DERMATOLOGY
MOHS SURGERY OPERATIVE REPORT
Referring Physician: G N/A ________________________
Pictures: G Pre-op G Intra-op G Post-op
Tumor Site: ____________________ Pre-op dx: _______________________ Post-op dx: ________________________ G Same
Indication: G Site G Size G Pathology G Recurrence G Incomplete excision G Indistinct borders
Recurrence History: G Primary G Recurrent Allergies: G NKDA G ______________________________________________
Taking anticoagulants: G No G ASA G NSAID G Coumadin G Plavix G ___________________________________
Preoperative Medication: G Meds reviewed & reconciled G N/A G antibiotic G Other ______________________________
Pre-op Assessment of Regional Nodes by palpation: G N/A G Negative G Positive
Vital Signs (Pre): Time: ________; Ht: ________ Wt: ________ B/P: ________ P: ________ Pain Score (Pre): ________/10
Time Out Conducted at: __________________ G AM G PM G Consent obtained
G Veried Correct patient (Name, DOB) G Correct patient position
G Correct procedure site and side (if applicable) G Correct procedure to be conducted
Equipment/supplies present: Yes No NA Pre-op antiseptic: Chlorhexidine Betadine Alcohol Lid Scrub
Procedural site is marked by proceduralist and veried: G Patient G Photo
H&P was performed just prior to the procedure or is available for review prior to the start: Yes No
Anesthetic: G Lidocaine 1% with epi 1:100,000 ____________________ G Bupivacaine 0.25% with epi 1:200,000
Curettage: G Yes G No Skin specimens process for frozen sections
Excision Size (cm) Post-Stage Size (cm) #Blocks Blocks positive
Stage I (preop________________ _______________________ __________ ___________________
Stage II _______________________ __________ ___________________
Stage III _______________________ __________ ___________________
Stage IV _______________________ __________ ___________________
Stage V _______________________ __________ ___________________
Perineural invasion: G yes G no
Depth of surgery: G dermis G fat G fascia G muscle G perichondrium G periosteum G cartilage G bone
Repair
Method: G 2nd intention G Intermediate G Complex G Flap G FTSG G STSG G Porcine graft
Anesthetic: G Lidocaine 1% with epi 1:100,000 ____________________ G Bupivacaine 0.25% with epi 1:200,000
Indication: G close open wound G extensive undermining G Burow’s triangles removed
G lack of local tissue G preserve form/function of _____________
Flap Movement: G N/A G Superior G Inferior G Medial G Lateral
Flap Subtype:
G
Advancement
G
Rotation
G
Rhombic
G
Transposition
G
Island
Graft: G Full thickness G Split thickness Donor site_______________________
Undermined: G N/A G fat G above fascia G subgalea G above periosteum
Sutures/Staples: G N/A Deep ___________ Skin ____________
Estimated Blood Loss: _______ mL _____ Complications: No Yes_________
Dressing: G Mupirocin/Gauze/Tape G Petrolatum G Other _________________
Condition of Patient: G Satisfactory G Other __________________
Vital Signs (Post): Time_______; B/P______ P_____ Pain Score (Post): _____/10
Postop Instructions (written & verbal): G patient G caregiver
Disposition: G Patient was discharged in satisfactory condition.
Medication prescribed:
G antibiotic __________________________ G pain _________________________
Staff Physician _______________________ Resident _________________________
(Print) (Print)
Physician’s Signature________________________ Date_________ Time_________
Patient Identication
MR Form D3155-103 1/13
Length ___________cm; Area ___________cm
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