Appendix A – Biopsy Log Policy

In the manual since June 26, 2020

Saint Louis University Department of Dermatology

Biopsy Log Policy

BIOPSY PERFORMED:

RN/LPN/Medical Assistant to record each biopsy performed that day in Biopsy Log Book. Documentation will include patient identification sticker, attending and resident physician, date, biopsy site, type of biopsy, and differential diagnoses.

BIOPSY FOLLOW-UP:

Biopsy report is placed in the ordering physician’s EPIC In Basket for review.
Physician will indicate/document patient notification and treatment plan in a Result Note and forward the results and plan to the appropriate Medical Assistant/Nurse.
Nurse/Medical Assistant records biopsy result and treatment plan in Log Book, dates and initials.
Nurse/MA will be assigned to review Log Book weekly for posted results and documentation to support patient notification of results. Biopsy results would be expected within two weeks of biopsy date.
If two weeks have lapsed from date of biopsy and results are not posted, the nurse/MA will search/call dermpath for results.
Physicians will forward any Mohs’ letters to the nurse/MA in order to facilitate documentation of treatment.
Nurse/MA will review Log Book for documentation to support skin cancer treatment within three months of biopsy. If documentation does not exist to support treatment of skin cancer within three months, RN/MA will review medical record and follow up with patient.
Nurse/Medical Assistant will document in the Log Book the treatment of skin cancers when performed in this office.
Residents will be assigned months of coverage for the biopsy logbook and are required to initial each entry of the book for their months of coverage (after diagnosis entered for benign diagnoses; after definitive treatment entered for any skin cancers). If after four months from time of biopsy documentation does not exist to support treatment of skin cancer, the resident will review medical record and follow up with patient. The goal is to make the patient aware of the diagnosis and to help the patient to arrange treatment for his or her malignancy. The resident will continue to follow the case until the malignancy is treated (not just scheduled for definitive treatment). Otherwise, the resident will document if the patient has died, received treatment elsewhere, refused treatment, or after three unsuccessful attempts via phone- send a certified letter. All communication should be documented in the patient’s medical record and a final note in the biopsy book. Each assigned month should be completed a maximum of 6 months following the assigned month. If a resident is to remove a biopsy book from the clinic, they must sign the book checkout located in the central clinic cabinets.

Tips for documentation:

Diagnosis clarity: Specify if the lesion is malignant (and list the diagnosis) or benign (optional to list the benign diagnosis).
Treatment documentation for malignancies: Use “s/p treatment with [specific treatment]” (e.g., “SCC s/p Mohs 7/2023”). Simply stating “SCC Mohs 7/2023” does not clarify whether Mohs was actually performed or just scheduled.
Multiple skin cancers: Include treatment details for each one.
Excisions: Note negative margins or no residual disease, rather than just stating “excision.”
Definitive treatment follow-up: If a patient was scheduled for treatment, document when it occurred. If treatment was not pursued, send and document a certified letter recommending treatment.
Standard abbreviations: Only use abbreviations commonly used in dermatology.
Initials: Either initial after each entry or initial once per page to confirm review.
Cultures: No need to document cultures in the biopsy book.

Example of good documentation:

✅ BCC s/p ED&C 10/31/23 LR

✅ Benign LR or EIC LR