Below is an example of Elliptical Excision Documentation. It may be changed to fit the procedure you performed.
A _____ year old ___________ [insert gender] presented for removal of a ___ cm lesion on the ____________ [insert anatomical location]. After obtaining informed written consent and performing a time out, the patient was placed in the ______ position. The lesion was identified and an appropriate border was marked. The skin was then prepped with betadine and sterily draped. Approximately ____ cc of local anesthesia was injected to good anesthetic effect. Using an elliptical incision, the lesion was excised in toto. The skin was closed with ___ [insert number] interrupted, non-absorbable stitches with good approximation. Antibiotic ointment and a sterile dressing were applied. The patient tolerated the procedure well. Tissue was sent for pathology. Discharge plans were given to the patient, including instructions to return in ____ [insert number] days for suture removal.