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Below is an example of punch biopsy documentation. It may be changed to fit your procedure.
A _____ year old ___________ [insert gender] presented for punch biopsy of a ___ mm lesion on the ____________ [insert anatomical location]. After obtaining informed written consent and performing a time out, the patient was placed in the ______ position. The skin was prepped with betadine and sterily draped. Approximately ____ cc of local anesthesia was injected to good anesthetic effect. Using a ___ mm punch, a sample was taken and sent for pathology. Hemostasis was achieved with ______ [a single interrupted, non-absorbable stitch or aluminum chloride and direct pressure]. Antibiotic ointment and a sterile dressing were applied. Discharge plans were given to the patient, including instructions to return in ____ [insert number] days for suture removal.
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