Patient Evaluation, Informed Consent, Preoperative Assessment, and Care

The consultation area

In general, a clean well-lit area will suffice for most purposes. Consider replacing the standard bulbs in fluorescent ceiling light fixtures with full-spectrum bulbs, which more accurately replicate the wavelengths of natural sunlight and better reveal skin tones. Full-spectrum light bulbs are relatively inexpensive and are readily available from retailers (including Lowe's, Walmart and Home Depot in the USA). A portable overhead light, or simply a flashlight, is useful for illuminating localized areas of skin that cause concern.

All consultation rooms should be equipped with a sink, along with a supply of clean towels and non-irritating facial cleanser because patients may need to remove their make-up to allow for adequate cutaneous examination. Mirrors, both hand-held and wall mounted, are essential for allowing patients to point out particular areas of concern.

A powered examination table is desirable and allows for comfortable and safe positioning of patients during the physical examination (see Chapter 51 ). Although the cost of these tables can be significant, certain discounts and tax deductions may be available when purchasing at a professional society exhibit, or under the Americans with Disabilities Act; interested physicians should consult their tax professional. In addition, all rooms should be equipped with comfortable chairs in which patients and their companions can wait before the consultation.

Consider placing pamphlets detailing the various procedures performed in your office on wall-mounted racks. Digital media displaying information on health and wellness, current events, weather and procedure simulation is a worthy investment. If patients will be spending appreciable time waiting in the room, a supply of current magazines is also a nice diversion.

During the initial preoperative consultation, it is important for the physician to respect and maintain the patient's privacy. An opaque, retractable curtain in all rooms for patients to change behind is an invaluable fixture. The consulting physician should attempt to give his/her complete attention to the patient during the visit. Unnecessary distractions, whether from incoming phone calls, pagers, or office staff interruptions, should be kept to a minimum.

Components of the preoperative consultation

The primary goals of the preoperative consultation are to evaluate, to educate, and to obtain informed consent. While the exact details of the initial consultation may vary, depending on such factors as whether or not the patient is new to the practice, the patient's prior medical knowledge, and particular medical problem, the overall components of the preoperative consultation remain unchanged. The following six elements should be included in every preoperative consultation:

• Medical history

• Surgical history with an emphasis on past dermatologic and/or cosmetic procedures

• Complete medication list including use of over-the-counter (OTC) drugs, vitamins, and nutritional supplements

• Problem-focused physical examination, including documenting the exact location of the lesion using clinical photographs or a 3-point coordinate system ( Fig. 5.1 ).

  • It is essential to communicate with referring physicians regarding the exact location of the biopsy site. Often, at the time of consultation, the original biopsy site may not be apparent. Clinical photographs or diagrams with accurate measurements with a ruler using at least three anatomical landmarks as reference points are helpful. More recently, web-based applications (e.g., anatomymapper.com) have become available to document biopsy and treatment sites.

  

• Social history

• Detailed explanation of the proposed procedure, treatment alternatives, and informed consent.

Medical history

The basic components of a medical history include a detailed account of current and past medical conditions, possible drug or latex allergies, as well as current drug and nutritional supplement use with special attention to conditions that can impact the outcome of the procedure. A preoperative questionnaire completed by the patient or with the help of medical staff (nurses, medical assistants, or physician assistants) facilitates the consult and provides useful information. Pre-printed patient questionnaires or an electronic medical record (EMR) template assures the key components of the preoperative assessment are addressed. A sample electronic medical record template for a Mohs consultation is shown in Box 5.1 . This template will vary depending on the specific procedure and can be further modified to meet the needs of each practice.