Availability of Biopsy Site Documentation for Mohs Surgery

Abstract

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.

Improved diagnosis by automated macro‐ and micro‐anatomical region mapping of skin photographs

“…While lesions locations could theoretically also be extracted by text mining patients records, this information should be accurately documented and properly linked to the corresponding patients images, which is not usually the case in clinical practice where reported locations can be imprecise. 3 , 4 One of our DLMs purposes is especially to assist clinicians in reporting accurate locations. The DLMs presented in this work can be regarded as a building block for future automated DD systems.…”

“…Mohs micrographic surgery is a common operation in dermatology to remove cancerous lesions. In practice, surgeons are regularly confronted with situations where lesion's locations defined in a patient's profile are imprecise, sometimes wrong 3 . These mistakes happen due to the sheer number of different regions in the human anatomy and the difficulty of remembering them all, even for experienced clinicians.…”

“…In practice, surgeons are regularly confronted with situations where lesion's locations defined in a patient's profile are imprecise, sometimes wrong. 3 These mistakes happen due to the sheer number of different regions in the human anatomy and the difficulty of remembering them all, even for experienced clinicians. To avoid wrong site surgery, the anatomical description of biopsy sites is crucial as they may heal scar‐free and the remaining tumour may become invisible.…”