Surgery Operative Report

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DEPARTMENT OF DERMATOLOGY MOHS SURGERY OPERATIVE REPORT Patient Identification 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 Verified 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 verified: 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 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 Perineural invasion: G yes G no De.

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