Minor Surgery record

GP Clinic – Minor Surgical Procedure Record Patient Details: [Patient full name] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.) [Patient DOB and/or NHI] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.) [Date and time of procedure] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.) [Name of clinician performing procedure] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.) [Name of nurse or assistant present] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.) Referral & Clinical Background: [Referring clinician or source] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.) [Lesion history, including onset, duration, and symptoms] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write in paragraph format.) Lesion Description: [Lesion characteristics – size, colour, surface, border] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write in sentence format.) [Lesion location] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.) [Previous treatment(s) for lesion] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.) [Provisional diagnosis] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.) Procedure Details: Procedure performed: [ ] Ellipse Excision [ ] Flap [ ] Punch Biopsy [ ] Other: [Specify] (Mark with "[x]" if information is explicitly mentioned in the transcript, contextual notes, or clinical note, and leave "[ ]" for information not explicitly mentioned. Do not omit any categories, even if nothing is reported.) Anaesthetic used: [ ] Lignocaine 1% [ ] Lignocaine 2% [ ] Lignocaine with Adrenaline (Mark with "[x]" if information is explicitly mentioned in the transcript, contextual notes, or clinical note, and leave "[ ]" for information not explicitly mentioned. Do not omit any categories, even if nothing is reported.) [Anaesthetic dose in mL] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.) [Batch number of anaesthetic] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.) [Expiry date of anaesthetic] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.) Sutures: [Type and size of sutures] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.) [Number of sutures placed] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.) Dressings: [Dressings applied post-procedure] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.) Post-Operative Instructions: Patient advised on: [ ] Wound care [ ] Signs of infection [ ] Analgesia [ ] Emergency contact (Mark with "[x]" if information is explicitly mentioned in the transcript, contextual notes, or clinical note, and leave "[ ]" for information not explicitly mentioned. Do not omit any categories, even if nothing is reported.) [Date of next check / dressing change] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.) [Planned number of days until suture removal] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.) Return to: [ ] Own GP [ ] This clinic (Mark with "[x]" if information is explicitly mentioned in the transcript, contextual notes, or clinical note, and leave "[ ]" for information not explicitly mentioned. Do not omit any categories, even if nothing is reported.) Histology: Specimen sent: [ ] Yes [ ] No (Mark with "[x]" if information is explicitly mentioned in the transcript, contextual notes, or clinical note, and leave "[ ]" for information not explicitly mentioned. Do not omit any categories, even if nothing is reported.) [Specimen site/description] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.) [Laboratory or courier details] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.) Histology result: [ ] Awaiting [ ] Received (Mark with "[x]" if information is explicitly mentioned in the transcript, contextual notes, or clinical note, and leave "[ ]" for information not explicitly mentioned. Do not omit any categories, even if nothing is reported.) [Action required based on histology result] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.) Sign-off: [Clinician name and signature] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.) [Date of clinician sign-off] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.) [Nurse/assistant name and signature] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.) [Date of nurse/assistant sign-off] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.) (Never come up with your own patient details, clinical findings, procedures, or follow-up plans – use only the transcript, contextual notes or clinical note as a reference for the information to include in your note. Only include a placeholder if it has been explicitly mentioned in the transcript or context — otherwise omit the section completely. Write all measurements and numerical values in digits, not words. Use bullet points or structured options where appropriate to reflect how the information was communicated.)