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BP:
/
|
P:
|
|
|
|
|
Anatomic location:
|
Anatomic Direction:
|
|
Pre-Op Size (in mm):
|
Post-Op Size (in mm):
|
|
Tumor Type at Biopsy:
|
Clark Level
|
|
Other Type:
|
Breslow Level (in mm)
|
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|
|
|
Stains:
• • •
|
|
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Primary Tumor:
|
|
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Recurrent Tumor:
• • •
|
|
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Indications for surgery:
• • •
|
|
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Pre-Op Medications:
• • •
|
If Other
|
|
Anesthetic
• • •
|
If Other
|
|
Tumor type at time of Mohs
• • •
|
|
|
Macroscopic Tumor Invasion:
• • •
|
|
|
Microscopic Tumor Invasion:
• • •
|
|
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Nerve involvement:
|
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|
|
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Stage 1 (note)
|
|
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Start Time:
|
End time:
|
|
Sections:
|
Anesthesia (CC's)
|
|
|
|
|
Stage 2 (note)
|
|
|
Start Time:
|
End time:
|
|
Sections:
|
Anesthesia (CC's)
|
|
|
|
|
Stage 3 (note)
|
|
|
Start Time:
|
End time:
|
|
Sections:
|
Anesthesia (CC's)
|
|
|
|
|
Stage 4 (note)
|
|
|
Start Time:
|
End time:
|
|
Sections:
|
Anesthesia (CC's)
|
|
|
|
|
Stage 5 (note)
|
|
|
Start Time:
|
End time:
|
|
Sections:
|
Anesthesia (CC's)
|
|
|
|
|
Stage 6 (note)
|
|
|
Start Time:
|
End time:
|
|
Sections:
|
Anesthesia (CC's)
|
|
|
|
|
Stage 7 (note)
|
|
|
Start Time:
|
End time:
|
|
Sections:
|
Anesthesia (CC's)
|
|
|
|
|
Stage 8 (note)
|
|
|
Start Time:
|
End time:
|
|
Sections:
|
Anesthesia (CC's)
|
|
|
|
|
Stage 9 (note)
|
|
|
Start Time:
|
End time:
|
|
Sections:
|
Anesthesia (CC's)
|
|
|
|
|
Stage 10 (note)
|
|
|
Start Time:
|
End time:
|
|
Sections:
|
Anesthesia (CC's)
|
|
|
|
|
Blood Loss:
|
|
|
Condition of Patient
|
|
|
Complications
|
|
|
Post-Op Antibiotics
|
Dosage:
|
|
Post-Op Pain Medication
|
Dosage:
|
|
Disposition of Wound
|
Reconstruction by Others:
|
|
|
|
|
Reconstructive Surgeon:
|
|
|
Reconstruction Method:
|
Skin Flap Type:
|
|
Dressing:
|
Skin Flap Type:
|
|
Visiting Nurse ordered:
|
Visiting Nurse Agency
|
|
Disposition of patient:
|
Disposition time:
|
|
|
|
|
Patient will return to our office days/weeks:
/
|
Patient will return to Dr days/weeks:
|
