Minor Surgical Procedure

Patient Name: John Doe Date of Birth: 01/01/1980 Date of Visit: 10/10/2023 Medical Record Number: 123456 Visit Type: Minor Surgical Procedure Procedure Performed: Excision of Skin Lesion Procedure Date: 10/10/2023 Indication for Procedure: Clinical Reason: Removal of suspicious skin lesion Previous Management: Topical treatments, monitoring Pre-Operative Assessment: Medical History: Relevant Past Medical History: Hypertension Allergies: Allergic to penicillin Medications: Lisinopril 10 mg daily Physical Examination: Site of Procedure: Left forearm Description of Lesion/Area: 1 cm pigmented lesion, no signs of infection Other Relevant Findings: Normal general examination Informed Consent: Consent Obtained: Yes Details Discussed: Procedure details, potential risks, benefits, and aftercare Procedure Details: Procedure Performed: Type of Procedure: Excision of skin lesion Anaesthesia Used: Local anaesthesia - 1% lidocaine Technique: Lesion excised with margins, site cleaned and sutured Instruments Used: Scalpel, forceps, sutures Duration of Procedure: 15 minutes Findings: Pre-Operative: Lesion appeared benign, no signs of ulceration Intra-Operative: Lesion excised with clear margins Post-Operative: Site well-hemostatized, no excessive bleeding Specimen Handling: Type of Specimen: Skin lesion Sent for Histopathology: Yes Specimen Labeling: Patient’s name, procedure date Post-Operative Instructions: Care Instructions: Wound Care: Keep the area clean and dry, apply antibiotic ointment as prescribed Dressings: Change dressing daily or if it becomes wet Signs of Complications: Redness, swelling, increased pain, fever Activity Restrictions: Avoid strenuous activity for 1 week Pain Management: Medications Prescribed: Paracetamol 500 mg, take as needed for pain Dosage Instructions: 1 tablet every 6 hours as needed Follow-Up: Appointment for Suture Removal: 10/17/2023 Date for Results Review: 10/24/2023 Emergency Contact Information: Contact Details: Provided patient with contact details for any concerns or emergencies. Patient Education: Information Provided: Wound Care Instructions: Written instructions provided Signs of Complications: Discussed verbally and written information provided Follow-Up Appointment: Confirmed with patient and written information given Signature: Dr. Thomas Kelly General Practitioner [Provider’s Contact Information] Date: 10/10/2023