🩺 Minor Surgery

💷 How much is this worth to me?

This template helps practices:

• Meet LES/DES claims for minor surgical procedures

• Maintain a compliant audit trail for CQC and indemnity bodies

• Record informed consent, procedure details, and complications

• Submit activity reports to commissioners (if required)

Correct completion ensures you're paid for minor ops and protects the practice medico-legally.

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📊 High-level overview of the specification requirements

Most minor surgery LES specifications require:

• Proper pre-op assessment

• Documented consent

• Full procedure note including:

  • Anaesthetic used

  • Material excised

  • Complications

• Arrangements for aftercare and follow-up

• Submission of activity logs or coding to your ICB

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📌 What do you need to know?

The template guides you through each required step.

🧾 Patient Consent

• Confirm:

  • Patient understands procedure and risks

  • Verbal or written consent taken

  • Consent for photos if applicable

✂️ Procedure Details

• Document:

  • Type of procedure (e.g. excision, aspiration, joint injection)

  • Site and side

  • Local anaesthetic used and amount

  • Skin prep (e.g. chlorhexidine)

  • Type of closure (sutures, steristrips, glue)

🧬 Sample and Histology

• Specify:

  • What was removed

  • Whether a sample was sent for histology

  • Label and container used

❗ Complications and Aftercare

• Tick if:

  • Procedure was uncomplicated

  • Bleeding, infection, or other issues occurred

• Aftercare advice given:

  • Wound care

  • When to seek medical attention

  • Suture removal timeline

📅 Follow-up Plan

• Record:

  • Who will review the wound

  • Timeline for follow-up

  • Whether a diary date has been set or recall created

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💡 Hints and Tips

• Always code the procedure AND diagnosis to trigger correct claims and reporting

• Can be used for:

  • Joint injections

  • Incisions/drainage

  • Skin excisions or removals

  • Cryotherapy or cautery

• Attach images or scan consent if required by your local commissioner

• Use in combination with the OneDiary or Follow-Up templates to set review reminders

• You may wish to log procedures in a local Minor Surgery Logbook