UCSF DERMATOLOGIC SURGERY and LASER ... - Dermatology

UCSF 

DERMATOLOGIC SURGERY and LASER CENTER 

PROCEDURE AND PROTOCOL MANUAL 

Mohs SURGERY 

Contents PAGE # 1 

1. Procedures 

a. Mohs 

i. Patient Pre-Preparation PAGE # 2 

ii. Patient Preparation--Procedure Day PAGE # 3 

iii. Staff Preparation--Procedure Day PAGE # 4 

iv. Mohs Equipment Set-Up PAGE # 5 

v. Pre-Operative Site Preparation PAGE # 6 

vi. Operative Procedure PAGE # 7 

vii. Post Operative Procedure PAGE # 8 

viii. Closure of the Mohs Wound PAGE # 9 

ix. Instrument Inventory PAGE # 10 

x. Form Inventory PAGE # 11 

xi. Picture and Sterile processing PAGE # 12 

Reviewed and Approved 

Roy Grekin, M.D. Medical Director 

Signature and Date:_____________________________ 

Page 1 of 12 

Updated March 7 2005 

Roy Grekin, M.D. Medical Director





Patient Pre-Preparation 

Prior to patient’s appointment, Nurse calls the patient and reviews: 

Micrographic Surgery Health Questionnaire (Form 796-057.) Advises: 

1. Shower and shampoo within 24 hours of their procedure to minimize bacterial growth on 

their skin. Document all instructions given. 

2. Screens for significant health issues: 

a. Allergies 

b. Immuno suppression 

c. Cardiac conditions needing anti-biotic 

3. Patient needs to inform the practice of any signs and/or symptoms of infection. (Increase 

in temperature, inflammation, redness, swelling or drainage on their skin.) If these 

symptoms are present, reschedule the surgery if determined by Surgeon. 

Page 2 of 12 







Patient Preparation--Procedure Day 

Nurse/LVN/MA team member labels, reviews and completes: 

1. Authorization For Surgery (Form 862-001Z) 

a. Line 1) Form must include Surgeon, Procedure and Site, 

b. Line 4) “complications involved have been explained by Doctor” (fill in 

Surgeon.) 

c. Section Donating Tissue for Medical Research. Please answer Yes or No to each. 

d. Patient signature and date. 

e. Witness to the signature (by staff) and date. 

2. Arm band 

a. Place patient label on arm band and place on patient’s arm 

3. Pre Procedure Verification Form (Form 602-820) 

a. A member of the surgery team must answer lines 1 – 10. 

b. Signature of MD/RN/Unit Staff and date must be included. 

Page 3 of 12 







Staff Preparation--Procedure Day 

Surgeon and Nurse/LVN/MA team members are to be properly attired for Clean Procedure with: 

1. Surgical bottoms and tops, bonnet (all hair should be enclosed), mask, protective eye 

shield. 

2. Hand-washing with 4% CHG is done before and after each patient encounter. All active 

member of the surgical team need to perform a pre-op surgical scrub of the hands to 

forearm and the elbows for at least 2 minutes with 4% CHG. 

3. Dry hands with a sterile towel and don appropriate gloves. 

Page 4 of 12 







Mohs Equipment Set-Up 

The Nurse/LVN/MA will set up the Mohs procedure room following guidelines. 

1. One sterile Towel Pack: 

a. Open and place on Mayo stand, using the drape for Mayo cover. 

b. Place towels on the drape at the right side of tray. 

2. IF First Sage, open one Sterile # 3 Curette and place on right side of tray. 

3. One sterile Mohs Pack: 

a. Open and place instruments to the left of the towels and at bottom of tray. 

b. Place blade remover to the left of the towels at the top of the tray. 

4. Petri Dish 

a. Attach Patient Label on dish, add Filter paper. 

b. Place on left lower corner of tray. 

5. Knife Blade, # 15 Attach to knife handle and return to tray. 

6. Dr. Tope additional instrument: 

a. Add one Bishop-Harmon toothed forceps. 

7. Clean Supplies--Place Q tips, cotton balls, gauze and card to the left of the towels at the 

top of the tray. 

a. Q tips 6" 10 each 

b. Cotton balls 3 each 

c. Gauze 4x4 10 each 

d. 4x6 CARD (or similar) 

8. Hyfrecator 

a. Cover cord with Penrose/Sleeve 

b. Add New Tip--Sharp or Blunt Determined by Surgeon 

9. Suction Tip disposable, available in room if needed. 

10. One Tissue Pack: 

a. Open and place on steri-pack paper on counter adjacent to Mayo tray, throw away 

clear plastic. These two instruments are used throughout day for multiple stains. 

These instruments do not come in contact with patient. 

Page 5 of 12 







Pre-Operative Site Preparation 

1. Prior to procedure, cleanse the lesion with alcohol to remove gross contamination of the 

skin. 

2. Using gloves, cleanse the lesion in concentric circles with Hibiclens or equivalent UCSF 

Medical center product. Start at the lesion and move out to he periphery. 

3. Allow the area to dry for two minutes. 

4. If the lesion is located around the nose, with an applicator soaked with Hibiclens or 

equivalent UCSF Medical center product, wipe each nares. 

5. Wipe away the Hibiclens or equivalent with an alcohol packet. 

6. The Surgeon will use a second alcohol packet to cleanse the lesion immediately before 

the local anesthesia is injected. 

Page 6 of 12 







Operative Procedure 

1. Prep the surgical site with Hibiclens or UCSF Medical center equivalent, starting at the 

session and moving out to the periphery. The area should be large enough to extend the 

incision or create another incision if needed. 

2. Drape the sterile towels with the surgical site exposed. 

3. Micrographic Surgery Operative Map (Form 796-058) must be labeled and placed 

adjacent to patient on wall. 

a. The surgeon identifies site location and maps procedure. 

4. Micrographic Surgery Operative Report (Form 796-056) 

a. Label the form 

b. Complete pre-operative patient information 

c. Take 1 st set of vitals and document (Note there are three vitals taken throughout 

process. 1 st prior to surgery, 2 nd prior to reconstructive procedure, 3 rd prior to 

discharge.) 

d. STOP. 

i. Surgeon, prior to any injections or incisions a Pre-Procedure Time Out 

must be performed. Verify “consent signed, witnessed and dated” and Two 

Patient Identifiers are noted and documented. 

5. The Surgeon will perform the initial stage of the Surgery. The assistant will maintain a 

clean field by suctioning the drainage or hyfrecating the vessels. 

6. Cleanse the \wound with sterile Normal Saline to remove the Hibiclens or equivalent on 

the skin. 

7. A pressure dressing is applied to the wound. 

Page 7 of 12 







Post Operative Procedure 

1. After marking the tissue with dye, the surgeon places the tissue on the filter paper in the 

Petri dish and gives it to the Mohs technician for processing with frozen sections. 

2. Subsequent stages follow the procedures as described above. 

3. New Room and Equipment set-ups are established between stages. 

4. Surgeon 

a. Remove Knife Blade and Syringe Needle and dispose in Sharps container. 

5. Nurse/LVN/MA 

a. Dress wound. 

b. Verify Knife Blade and Syringe Needle were disposed in Sharps container. 

c. Remove Hyfrecator Tip and Sleeve. 

d. Remove Suction Tip and dispose of, if used. 

e. Remove all used Towels and Instruments and disposable supplies to clean 

processing area. 

f. Prepare room for next patient. 

Page 8 of 12 







Closure of the Mohs Wound 

When the patient is cleared of his skin cancer, prepare the patient for the closure or repair of the 

wound. 

1. See Excision Repair Procedure 

2. After the Procedure, the RN/LVN/MA will label and review with the patient: 

a. Patient Instructions Wound Care for Dermatology (Form 785-032A.) 

b. Verify patient understands how to contact Practice. 

c. Verify patient has any prescriptions from the Surgeon. 

d. Verify 3 rd vital has been taken and documented on the Micrographic Surgery 

Operative Report (Form 796-056). 

e. If patient does not have a companion to drive them home, verify patient is alert 

and responsive to all questions. 

f. Verify patient signs and dates Patient Instructions Wound Care for Dermatology 

(Form 785-032A.) 

Page 9 of 12 







Instrument Inventory 

ITEMS 

CURRETTE PACK 

CURETTE SINGLE PACK 1ST STAGE ONLY 

BISHOP-HARMON FORCEP 

TOOTHED SINGLE PACK TOPE ONLY 

Mohs STAGE PACK 

INSRUMENTS 

HANDL, # 3 1 

SCISSORS STRABISMUS 4 1/2" CURVED RIBON TYPE 1 

FORCEPS, ADSON 4 3/4 " SERRATED 1x2 TEETH 1 

BLADE REMOVER 1 

Mohs SUPPLIES added to tray 

4x6 CARD 1 

GAUZE 4x4 10 

COTTON BALLS 3 

Q TIPS 6" 10 

TOWEL PACK 

TOWEL 12"x24" 4 

WRAPPER--DISP--USE AS TRAY DRAPE FOR Mohs PACK 1 

TISSUE PACK 

SCISSORS, IRIS 4" STRAIGHT 1 

FORCEPS, ADSON 4 3/4 " SERRATED NON TOOTHED 1 

KNIFE BLADE # 15 DISPOSABLE 

USED ONE PER ROOM 

ALL DAY 

USED ONE PER ROOM 

ALL DAY 

AS DISTRIBUTED BY 

VENDOR, PLACED PER 

STAGE-- NOT PART OF 

OR OUR STERILE 

PROCESS 

Page 10 of 12 







Forms to be used 

PROCEDURES 

FORM # FORM TITLE MOHS MOHS FUP INJECTIONS EPILASER LASER EVA 

NA LABELS YES YES YES YES YES YES 

785-052 ENCOUNTER COSMETIC YES YES YES 

785-051 ENCOUNTER SURGERY YES 

785-054 ENCOUNTER MOHS YES YES 

834-001 HISTORY PROGRESS NOTE YES YES YES YES YES YES 

862-001Z CONSENT YES YES YES YES YES 

602-820 PRE-PROCEDURE VERIFICATION FORM YES YES YES YES YES 

796-057 MICROGRAPHIC HEALTH QUESTIONAIRE YES 

796-056 MICROGRAPHIC OPERATIVE MAP YES 

796-058 MICROGRAPHIC SURGERY OPERATIVE REPORT YES 

785-032A WOUND CARE YES YES 

785-019 MINOR PROCEDURE REPORT YES 

678-002 PATHOLOGY 

796-055 SURGERY OPERATIVE REPORT 

796-059 LASER SURGERY REPORT YES 

LASER WC YES YES 

LASER LOG YES YES 

EPI Hx YES 

EPI COST YES 

785-033 PATIENT INSTRUCTIN LASER POST TREATMENT 

862-002 CONSENT PHOTOGRAPH AND PUBLICATION 

785-036 CONSOLT RECORD ROY GREKIN YES 

Page 11 of 12 







Pictures and Sterile processing procedure 

Page 12 of 12

UCSF DERMATOLOGIC SURGERY and LASER ... - Dermatology

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