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Below is an example of Shave Excision documentation. It may be changed to fit your procedure.
A _____ year old ___________ [insert gender] presented for excision of a ___ mm lesion on the ____________ [insert anatomical part]. After obtaining informed verbal consent and performing a time out, the patient was placed in the ______ position. Skin was cleansed with alcohol. Approximately 1 cc of local anesthetic was injected to good effect. Using a razor, the lesion was shaved in toto and sent for pathology. Hemostasis was achieved with direct pressure and application of aluminum chloride. Patient tolerated the procedure well. Antibiotic ointment and a sterile dressing were applied. Discharge instructions were given.
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