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Service Date/Time: [date] Document Type: Plastics Clinic Procedure Document Subject: Procedure Note Result Status: Auth (Verified) Electronically Signed By: Huq, Nasimul S., MD, MSc, FACS, FRCSC, MD, MSc, FACS, FRCSC ([date]) Procedure: Thanks for your kind referral of this patient who was seen in the Niagara Falls hospital for [Condition/Concern]. On examination, the area of concern was identified and confirmed with the patient. The rest of the past history, medications, allergies and physical exam have been reviewed and noted. The various options were reviewed and the risks and complications of operative and non-operative measures were discussed including but not limited to such things as pathologic scars being wide, raised, and red and shiny red scars such as hypertrophic or keloid scars, infections including wound healing problems, scar contractures as well as possible nerve injuries and changes in sensation around the areas of the exam, numbness, and the rare need of surgery, cosmetically unsightly changes and complications from the anesthesia. Tumours can recur. The patient may require further surgery. The patient was advised to consider all of the complications carefully. We ensured the time for discussion and ensured the patient understood the discussion in clear terms to their satisfaction. All questions were answered and informed consent was obtained. PRE OPERATIVE DIAGNOSIS: [Provide the pre-operative diagnosis in a number list, e.g., 1. bcc (basal cell carcinoma).] PROCEDURE: [[Describe the procedure performed, including details such as the type of excision, closure technique, defect size, and use of frozen sections.] For example: Excision of lesion on the right nose with a rotation flap closure for a defect of 1.7cm and frozen sections for tumor free margins.] [[Include details of the surgical process, such as surgical timeout, preparation, anesthesia used, excision technique, hemostasis, closure method, and specimen labeling.] [Document the patient's tolerance of the procedure, post-op instructions given, and follow-up arrangements.] For example: Surgical timeout was completed. The area of concern was identified, prepped and infiltrated with Xylocaine with Adrenaline and the procedure was done in a sterile fashion. The superior margin was sent for frozen sections. The lesion was excised with a few millimetres of the margin circumferentially. Hemostasis was easily achieved. The defect was measured. The area clearly would not close primarily. The rotation flap was elevated. Hemostasis was rechecked with electrocautery. Skin was closed in layers of an internal deep dermal layer and skin closure. The dressings were applied. The specimen was labeled with the pathology number at 12 o'clock.] All counts were correct at the end of the procedure. The final surgical time out was completed. The patient tolerated the procedure well. Post-op instructions were given. We will await the pathology results. A follow-up was arranged. Thanks again for your kind referral. Please don’t hesitate to contact me if there are any questions. Best Regards, N.S. Huq CONFIDENTIAL REPORT FOR REFERRING DOCTOR’S PERSONAL USE ONLY Electronically Signed on [date] Huq, Nasimul S., MD, MSc, FACS, FRCSC