Minor Surgical Procedure
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Andrew Kelly
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General Practitioner
Last edited
10/20/2026
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About this template
A reusable template for documenting minor surgical procedures, including patient details, indications, pre-operative assessment, procedural findings, specimen handling, post-operative care, education, and follow-up.
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Patient Name: Arthur Pendelton
Date of Birth: 14/05/1958
Date of Visit: 24/10/2023
Medical Record Number: MRN-849201
Visit Type: Minor Surgical Procedure
Procedure Performed: Excisional biopsy of skin lesion
Procedure Date: 24/10/2023
Indication for Procedure
Clinical Reason: Suspicious pigmented lesion on right forearm; rule out melanoma vs dysplastic naevus.
Previous Management: Monitored for 3 months with serial dermoscopy; noted recent enlargement and border irregularity.
Pre-Operative Assessment
Medical History
Relevant Past Medical History: HTN, hyperlipidaemia, previous BCC excised from nose (2019). No history of bleeding disorders or keloid scarring.
Allergies: NKDA.
Medications: perindopril (Coversyl®) 5 mg PO daily, atorvastatin (Lipitor®) 20 mg PO daily. No anticoagulants or antiplatelets.
Physical Examination
Site of Procedure: Right dorsal forearm, mid-shaft.
Description of Lesion/Area: 6 mm x 5 mm asymmetrical hyperpigmented macule with irregular borders and dual colouration on dermoscopy.
Other Relevant Findings: No palpable regional (epitrochlear or axillary) lymphadenopathy. Surrounding skin intact, no signs of infection.
Informed Consent
Consent Obtained: Yes, written and verbal consent obtained.
Details Discussed: Procedure steps, benefits (definitive histopathological diagnosis), and risks including bleeding, infection, scarring, wound dehiscence, nerve damage, and potential need for wider re-excision depending on pathology results.
Procedure Details
Procedure Performed
Type of Procedure: Elliptical excisional biopsy with primary closure.
Anaesthesia Used: lidocaine (lignocaine, Xylocaine®) 1% with adrenaline (epinephrine) 1:100,000, 4 mL infiltrated subcutaneously.
Technique: Area prepped with chlorhexidine 2% and draped in sterile fashion. Elliptical excision marked with 2 mm clinical margins oriented along relaxed skin tension lines. Incision made to subcutaneous fat. Lesion excised intact. Haemostasis achieved via pressure. Wound closed in single layer with 4-0 nylon interrupted sutures (4 sutures total). Sterile waterproof dressing applied.
Instruments Used: #15 scalpel blade, toothed forceps, needle holder, suture scissors.
Duration of Procedure: 20 minutes (14:10 to 14:30).
Findings
Pre-Operative: 6 mm x 5 mm pigmented macule on right dorsal forearm.
Intra-Operative: Lesion excised cleanly to mid-subcutaneous fat; no deep invasion noted macroscopically. Minimal bleeding.
Post-Operative: Wound edges well-approximated under minimal tension. Good haemostasis. Distal neurovascular status intact.
Specimen Handling
Type of Specimen: Skin ellipse, right dorsal forearm (12 mm x 8 mm x 4 mm).
Sent for Histopathology: Yes, placed in 10% formal saline and sent to Melbourne Pathology.
Specimen Labelling: Labelled with patient's full name, DOB, MRN, date/time of collection, and anatomical site ("Right dorsal forearm skin ellipse, suture at 12 o'clock / proximal margin"). Confirmed with patient.
Post-Operative Instructions
Care Instructions
Wound Care: Keep wound clean and dry for 48 hours.
Dressings: Leave initial waterproof dressing intact for 2 days, then replace with a clean dry dressing daily or if soiled.
Signs of Complications: Monitor for increasing redness, swelling, warmth, purulent discharge, persistent bleeding, or worsening pain.
Activity Restrictions: Avoid heavy lifting, strenuous exercise, or submerging the arm in water (baths, swimming) for 10 days.
Pain Management
Medications Prescribed: paracetamol (Panadol®) 500 mg tablets (OTC).
Dosage Instructions: paracetamol 1,000 mg PO QID PRN for pain (max 4,000 mg/24 hours). Avoid aspirin or NSAIDs for 48 hours to minimise bleeding risk.
Follow-Up
Appointment for Suture Removal: 03/11/2023 (in 10 days) with practice nurse.
Date for Results Review: 03/11/2023 with GP (concurrent with suture removal).
Emergency Contact Information
Contact Details: Provided clinic phone number (03 9555 1234) for business hours and advised to attend the nearest Emergency Department or call Nurse-on-Call (1300 60 60 24) after hours if urgent complications arise.
Patient Education
Information Provided
Wound Care Instructions: Written and verbal post-operative wound care handout provided.
Signs of Complications: Verbalised understanding of red-flag symptoms (infection, haematoma, dehiscence).
Follow-Up Appointment: Booked at reception prior to departure for 03/11/2023 at 10:00.
Signature
Dr Sarah Jenkins
General Practitioner, MBBS, FRACGP
Bayside Family Medical Centre, 124 Bay Rd, Sandringham VIC 3191 | Ph: (03) 9555 1234
Date: 24/10/2023
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