Note: ALL PAMF Dermatology reports that have biopsy/specimens sent for pathology require a pathology line at the bottom of the report to be typed by you. One line for each specimen sent.
(BODY PART): _____________________________________________________
Example: RIGHT CHEEK: ____________________________________________
JOB DESCRIPTION/TEMPLATES BY PHYSICIAN
DOCTOR'S NAME:
PHYSICIAN ID#: 0296
A. Christine Miller, M.D.
DEPARTMENT: Dermatology
LOCATION: PAMC
FORMAT:
Clinic Notes: General Paragraph
Letters: General Paragraph X
PROGRAMMED DICTATION:
Very Specific (See attached)
Very Specific
None: X Physical Other: (See attached)
OTHER IMPORTANT HELPFUL HINTS: Special requests, etc:
(See attached)

NOTE: IN CHARTSCRIPT, PLEASE SELECT 03 FOR WORK TYPE WHEN

TRANSCRIBING DERMATOLOGY CLINIC NOTES.

REGARDING MOHS PATIENTS – SEE ATTACHED AND SAMPLES.

Mohs Reports (use 03 work type for Mohs operative reports). See instructions & samples.

TEMPLATES:

Refer to extensive template listing on attached pages.

Follow usual Derm procedure for biopsy reports – When a specimen is removed and sent to pathology for biopsy, type the area of body that specimen was removed from at the bottom of the page and underline across entire page – see sample.
(body part) ______________________________________
Example:
RIGHT MID BACK _____________________________

ACM 1 :
MOHS' CLINIC NOTE
Patient comes for Mohs' surgery for ?? ?? ?? indistinct ?? cell carcinoma?? of the ?? ??. I have discussed the nature of the lesion?? with the patient. I have discussed the proposed
?? ?? Mohs' surgery in detail. ?? is aware that ?? large wound?? ?? ?? ?? result, that ?? ?? may be necessary, and that there ?? be ?? ?? permanent ?? scar ??. Patient states ?? understands and wishes to proceed with the surgery.
Thus after signed consent, Mohs' surgery was performed as per the accompanying operative report. ?? stage?? of excision and the removal of ?? tissue section? ?? necessary to achieve ?? tumor-free plane??. At the completion of excision the wound?? measured ?? ?? and ?? ?? ?? ??. After careful consideration of healing and repair options, it was elected to close this defect ?? ??. The patient tolerated the procedure well. ?? has been given detailed verbal and printed postoperative wound care instructions. ?? will minimize all physical activities ?? ?? ?? ?? ??. ?? will take Tylenol with Codeine No. 3 as needed for pain, return in ?? week??.
ACM2:
Local infiltration anesthesia was achieved with 1:1 ?? of 1 percent lidocaine with
1:100,000 epinephrine and 0.25 percent Marcaine with 1:200,000 epinephrine.
ACM3:
The patient was brought to the office operating room. Careful informed consent was obtained. Local infiltration anesthesia was achieved with the above agents. The operative site was prepped with chlorhexidine gluconate and draped sterilely. The tumor was initially debulked with sharp ??
ACM4:
Following debulking, with sharp excision, ?? Mohs' tissue ?? ?? taken which encompassed the entire periphery and base of the wound. Hemostasis was achieved with electrocoagulation and a temporary dressing was placed.
ACM5:
The tissue section? ??mapped, marked with tissue dyes for orientation, placed in the cryostat, frozen to ?? degrees Centigrade sectioned at eight to ten microns in the horizontal plane, placed on slides, stained with hematoxylin and eosin, and examined microscopically. ?? ??
ACM6:
The patient was returned to the office operating room. Local infiltration anesthesia was again achieved. The operative site was prepped and draped sterilely. With sharp excision, ?? Mohs' tissue ?? ?? taken which encompassed the prior area? ?? of involvement. Hemostasis was achieved with electrocoagulation and a temporary dressing was placed. The tissue ?? ?? mapped, marked, and processed as described above.
Microscopic examination revealed ??

ACM7:
The patient was returned to the office operating room. Photographs were taken. More extensive local infiltration anesthesia was achieved with the above agents. The operative site was prepped and draped sterilely. The margins of the wound were ?? undercut in the dermal-subcutaneous plane. Hemostasis was achieved throughout with electrocoagulation.
ACM8:
The patient has been given detailed verbal and printed postoperative wound care instructions. ?? is to minimize ?? physical activity ?? ?? ?? ?? ??. ?? will leave the ?? dressing undisturbed. ?? will perform daily dressing changes on the ?? ?? wound. ?? will take ?? or Tylenol with Codeine No. 3 as needed for pain. ?? will return in ?? ?? for ?? ??
??.
ACM9:
After signed consent, the area was anesthetized with local infiltration of 1:1 solution of 1 percent lidocaine with 1:100,000 epinephrine and 0.25 percent Marcaine with 1:200,000 epinephrine.
ACM 10 :
Under ?? 1 percent lidocaine local infiltration anesthesia I performed a ?? ?? ?? biopsy of the ?? ?? ??, Drysol as a styptic, ?? ?? ?? suture?? to close, Polysporin ointment and
Band-Aid dressing with verbal and printed instructions in wound care. I will notify patient by mail of the result of the biopsy and need for any further treatment. Patient to return in ?? ?? ?? ?? for suture removal and path results.
ACM 11 :
Thus after signed consent, the area was anesthetized with local infiltration of 1:1 solution of 1 percent lidocaine with 1:100,000 epinephrine and 0.25 percent Marcaine with
1:200,000 epinephrine. The operative site was prepped with chlorhexidine gluconate and draped sterilely. The visible skin cancer ?? and ?? small margin?? of normal-appearing skin was excised in ?? fusiform ellipse?? with the long axis parallel to the relaxed skin tension lines. The level of excision was into the upper subcutaneous fat. Following removal of the lesion the margins of the wound were undercut ?? in the dermalsubcutaneous plane. Hemostasis was achieved with electrocoagulation. The margins of the wound were advanced and closed ?? with buried ?? Vicryl sutures. The surface was closed with ?? interrupted ?? Prolene suture??. A Polysporin ointment, dry gauze and tape pressure dressing was applied.
The patient has been given detailed verbal and printed postoperative wound care instructions. ?? will take Tylenol or Tylenol with Codeine No. 3 as needed for pain. ?? will minimize physical activity. ?? will perform daily dressing changes ?? ??. ?? will return in ?? ?? for suture removal.
ACM 12 :

Under 1 percent lidocaine local infiltration anesthesia performed a ?? biopsy of ?? ?? ??,
Drysol as a styptic, Polysporin ointment and Band-Aid dressing with instructions on biopsy site care. I will notify patient by mail of the results and need for any further treatment.
ACM 13 :
MOHS' OPERATIVE REPORT
PATIENT NAME: ??
RECORD NUMBER: ??
DATE OF SURGERY: ??
INDICATIONS FOR SURGERY: ??
ANESTHESIA: ??
PROCEDURE: ??
STAGE I: ??
STAGE II: ??
STAGE III:
STAGE IV:
REPAIR: ??
??
??
POSTOPERATIVE CARE: ??
ACM 14 :
?? trunk, ?? extremity, head and neck check performed. ??
ACM 15 :
??, brown, waxy, ?? erythematous, keratotic, ?? stuck-on papule?? ??
ACM 16 :
?? denies allergies to medications. ?? denies a history of cardiovascular disease, hypertension, hepatitis, bleeding disorders, immunosuppression or diabetes. No artificial joints or heart valves. ?? does not smoke.
ACM 17 :
Discussion with patient. I have reviewed the nature of the lesion. I have discussed treatment options. I have discussed the proposed ?? ?? Mohs' surgery ?? in detail ?? with the patient. ?? is aware that ?? large wound?? ?? result, that ?? may be necessary, that

there ?? be ?? ?? permanent ?? scar ??. Patient ?? states ?? understands and wishes to go ahead with the surgery. ?? have scheduled ?? for the next convenient available Mohs' surgical appointment. ?? given ?? the usual preoperative instructions.
END MILLER …………………………………………………………………………….
JOB DESCRIPTION/FORMAT
DOCTOR'S NAME:
PHYSICIAN ID#: 3416
Kristen Vin-Christian, M.D.
DEPARTMENT: Dermatology
LOCATION: PAMC
FORMAT:
Clinic Notes: General Paragraph
General Paragraph Letters:
Very Specific:
Very Specific:
(See attached)
(See attached)
PROGRAMMED DICTATION:
None: Physical Other: (See attached)
OTHER IMPORTANT HELPFUL HINTS: Special requests, etc:

Use 03 for all notes

See attached templates for: Letters re: Mohs' surgical patients and Mohs' closure procedure (03).
 cc: Dr. Vin-Christian on all Mohs' surgical reports.

Follow usual Derm procedure for biopsy reports – When a specimen is removed and sent to pathology for biopsy, type the area of body that specimen was removed from at the bottom of the page and underline across entire page – see sample.
(body part) ______________________________________
Example:
RIGHT MID BACK _____________________________
VCMOH:
INDICATIONS: This ?? -year-old patient was referred by ?? for the treatment of ??.
Mohs surgery is indicated due to ??. The preoperative size is ??. The technique, its benefits, alternatives, and risks were discussed with the patient. After informed consent and appropriate instruction, the patient underwent Mohs surgery using fresh tissue technique as follows.

STAGE I: The patient was placed supine on the operative table. The lesion(s) were defined and infiltrated with lidocaine 1 percent with epinephrine. The area was sterilely prepped. The area was then curetted. An initial excision was made around the curettage markings, and hemostasis was obtained by electrodesiccation and dressings placed. The tissue was divided into ?? section(s) which were mapped, color coded at their margins, and sent to the technician for frozen sectioning. Microscopic tumor was found persisting in ?? specimen(s).
STAGE II: The patient returned to the operative suite. The area of positivity was delineated, infiltrated with lidocaine 1 percent with epinephrine, and excised. Tissue was divided into ?? section(s) which were again marked, color coded, and sent to the technician for frozen sectioning. Hemostasis was obtained in the usual manner and a dressing placed. Microscopic tumor was found persisting in ?? specimens.
With the lesions clear of microscopic tumor, surgery was considered complete.
Following surgery, the defect(s) measured as follows: ??. The defect(s) were closed by
??.
FINAL DIAGNOSIS: ??
CONDITION AT THE TERMINATION OF THERAPY: Carcinoma removed.
VCLO:
INDICATIONS: This ?? -year-old patient was left with ?? defect located on the ?? following Mohs surgery for ??. We discussed various closure modalities with the patient, including healing by second intention, skin graft, primary closure and various flaps, and felt that the location and configuration of the defect(s) indicated that ?? would result in the least disturbance of the position and function of the surrounding anatomic structures.
The technique, its benefits, alternatives and risks were discussed with the patient.
Appropriate instructions were given, informed consent was obtained, and then the patient underwent the procedure as follows:
PROCEDURE: The patient was taken to the operative suite and placed supine on the operating room table. The area of the defect(s) and the skin surrounding was anesthetized with 1 percent lidocaine with epinephrine. The area was washed with
Hibiclens and rinsed. Sterile drapes were applied.
??
FINAL DIAGNOSIS: ??
FINAL PROCEDURE: ??
COMPLICATIONS: None.

VC 1 - letter template:
We had the pleasure of seeing your patient, ??, today in our Mohs Surgery Unit.
As you may recall, this ?? -year-old patient presents with ?? of the ??. The lesion was removed today in a ?? stage, ?? section Mohs procedure. At the end of this procedure, the resultant defect measured ?? and was repaired by ??.
The patient tolerated the procedure well and there were no complications. Please find enclosed copies of our operative reports as well as photographs of the procedure for your records. Should you have any further questions, please do not hesitate to contact me.
Thank you very much for allowing me to participate in the care of your patient.
Sincerely,
Kristen Vin-Christian, MD
END VIN-CHRISTIAN …………………………………………………………………..
JOB DESCRIPTION/FORMAT
DOCTOR'S NAME: David G. Deneau, M.D.
PHYSICIAN ID#: 0020
DEPARTMENT: Dermatology
LOCATION: PAMC
FORMAT :
Clinic Notes: General Paragraph X
General Paragraph X Letters:
Very Specific
Very Specific
PROGRAMMED DICTATION:
None: X Physical Other: (See attached)
OTHER IMPORTANT HELPFUL HINTS: Special requests, etc:
(See attached)
(See attached)
 Use “03” for Derm Note.

See samples attached.

The usual for Dermatology procedure for biopsy reports is: When a specimen is removed and sent to pathology for biopsy, type the area of body that specimen was

removed from at the bottom of the page and underline across entire page – see sample.
(BODY PART) ______________________________________
Example:
RIGHT MID BACK __________________________________
END DENEAU……………………………………………………………….
JOB DESCRIPTION/FORMAT
Kathleen E. Kramer, M.D
. DOCTOR'S NAME:
PHYSICIAN ID#: 3272
DEPARTMENT: Dermatology
LOCATION: PAMC
FORMAT:
Clinic Notes: General Paragraph X Very Specific
Letters: General Paragraph X Very Specific
(See attached)
(See attached)
PROGRAMMED DICTATION:
None: X Physical Other: (See attached)
OTHER IMPORTANT HELPFUL HINTS: Special requests, etc:
Use 03 for document type for all Derm notes.
Follow usual Derm procedure for biopsy reports – When a specimen is removed and sent to pathology for biopsy, type the area of body that specimen was removed from at the bottom of the page and underline across entire page – see sample.
(BODY PART) ______________________________________
Example:
RIGHT MID BACK ___________________________________
END KRAMER
……………………………………………………………………………..

JOB DESCRIPTION/FORMAT
Rothman, Ruth, M.D. DOCTOR'S NAME:
PHYSICIAN ID#: 3183
DEPARTMENT: Dermatology
LOCATION: PAMC
FORMAT:
Clinic Notes: General Paragraph Very Specific
Letters: General Paragraph
PROGRAMMED DICTATION:
None: X Physical
X Very Specific
Other: (See attached)
(See attached)
(See attached)
OTHER IMPORTANT HELPFUL HINTS: Special requests, etc:

Use 03 for document type for all derm notes.

Follow usual Derm procedure for biopsy reports – When a specimen is removed and sent to pathology for biopsy, type the area of body that specimen was removed from at the bottom of the page and underline across entire page – see sample.
(body part) ______________________________________
Example:
RIGHT MID BACK _____________________________
END ROTHMAN
…………………………………………………………………………..
JOB DESCRIPTION/FORMAT
DOCTOR'S NAME:
PHYSICIAN ID#: 3289
DEPARTMENT:
LOCATION : PAMC
Dermatology
G. Scott Herron, M.D.
FORMAT:
Clinic Notes: General Paragraph Very Specific: (See attached)

Letters: General Paragraph: X
PROGRAMMED DICTATION:
Very Specific
None: X Physical Other: (See attached)
OTHER IMPORTANT HELPFUL HINTS: Special requests, etc:
(See attached)

Use 03 for all derm notes – 03 on job list.

Dr. Herron has 2 standard templates:
GH 1 FULL EXAM (note stop code at end. He will dictate the rest of sentence).

GH2 BIOPSY PROCEDURE.

Follow usual Derm procedure for biopsy reports – When a specimen is removed and sent to pathology for biopsy, type the area of body that specimen was removed from at the bottom of the page and underline across entire page – see sample.
(body part) ______________________________________
Example:
RIGHT MID BACK _____________________________
END HERRON
……………………………………………………………………………