Minor Surgery record

GP Clinic – Minor Surgical Procedure Record Patient Details: John Smith 12/03/1960, NHS Number: 1234567890 Date and time of procedure: 01/11/2024 10:00 Name of clinician performing procedure: Dr. Jane Doe Name of nurse or assistant present: Nurse Sarah Green Referral & Clinical Background: Referring clinician or source: Self-referral Lesion history, including onset, duration, and symptoms: The patient noticed a small, dark mole on his back approximately 6 months ago. It has gradually increased in size and has recently started to itch occasionally. Lesion Description: Lesion characteristics – size, colour, surface, border: 6mm, irregular border, dark brown, slightly raised surface. Lesion location: Upper back Previous treatment(s) for lesion: None Provisional diagnosis: Suspicious naevus Procedure Details: Procedure performed: [x] Ellipse Excision [ ] Flap [ ] Punch Biopsy [ ] Other: [Specify] Anaesthetic used: [x] Lignocaine 1% [ ] Lignocaine 2% [ ] Lignocaine with Adrenaline Anaesthetic dose in mL: 2mL Batch number of anaesthetic: ABC123 Expiry date of anaesthetic: 01/01/2026 Sutures: Type and size of sutures: 4/0 Vicryl Number of sutures placed: 4 Dressings: Dressings applied post-procedure: Steri-strips and a light dressing Post-Operative Instructions: Patient advised on: [x] Wound care [x] Signs of infection [x] Analgesia [x] Emergency contact Date of next check / dressing change: 7 days Planned number of days until suture removal: 10 days Return to: [x] Own GP [x] This clinic Histology: Specimen sent: [x] Yes [ ] No Specimen site/description: Excision of suspicious naevus, upper back Laboratory or courier details: Pathology Lab, City Hospital Histology result: [ ] Awaiting [x] Received Action required based on histology result: Patient to be informed of results and further management plan discussed. Sign-off: Clinician name and signature: Dr. Jane Doe (signed) Date of clinician sign-off: 01/11/2024 Nurse/assistant name and signature: Nurse Sarah Green (signed) Date of nurse/assistant sign-off: 01/11/2024