Availability of Biopsy Site Documentation for Mohs Surgery

Shari A. Ochoa, Naomi Lawrence

Research output: Contribution to journalArticlepeer-review


Patients presenting for Mohs surgery may have difficulty identifying their surgical site. Records from referring physicians do not always allow the surgeon to independently identify the site, which increases risk of a wrong-site surgery. We sought to quantify the number of referral cases for Mohs surgery with adequately detailed documentation for site identification by retrospectively reviewing 1000 sequential cases treated by a single physician academic surgical practice. The following information from the referring provider was abstracted for each case: photograph, measurement from an anatomic landmark, diagram, and nomenclature on the pathology report. One hundred ninety-six referrals (19.6%) were accompanied by documentation that adequately identified the biopsy site, independent of the patient's ability to recall the site; 23 (2.3%) had a photograph, six (0.6%) had a measurement from an anatomic landmark, and 167 (16.7%) had a diagram. The nomenclature used for biopsy sites on the pathology report specifically and correctly identified the anatomic location of the tumor for 293 referrals (29.3%). This study showed that most referrals for Mohs surgery lacked sufficient documentation to enable objective identification of biopsy sites.

Original languageEnglish (US)
Pages (from-to)273-276
Number of pages4
JournalJournal of the Dermatology Nurses' Association
Issue number5
StatePublished - Sep 1 2015


  • Anatomic Landmarks
  • Dermatology Procedures
  • Dermatology Surgery
  • Neoplasms
  • Referral and Consultation
  • Safety

ASJC Scopus subject areas

  • Advanced and Specialized Nursing


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