Preview Surgery Operative

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 Veried 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 veried: 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 Identication

MR Form D3155-103 1/13

Length ___________cm; Area ___________cm

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