Quality of Information in Dermatologic Surgery Referrals: A Prospective Observational Cohort Study

Accurate description of biopsy sites is critical to prevent wrong-site procedures, which carry serious patient safety and medicolegal consequences. Despite existing guidelines, insufficient site documentation remains a persistent challenge.

Identify factors associated with incorrect anatomical site descriptions in dermatologic surgery referrals.

Prospective, observational cohort of 1,000 consecutive referrals for surgery at a single private dermatologic surgery practice was assessed for correct anatomical site description, defined as concordance between documented biopsy location and the clinically evident lesion or scar at the time of surgery. Referral documentation was assessed for clinical photographs, anatomical diagrams, age, sex, tumor type, tumor location, lesion size, and referring provider type.

Anatomical location significantly influenced correctness (χ 2 = 22.47, p = .002), with nasal lesions more likely to be incorrectly described (residual = -3.64). Referrals including a clinical photograph (χ 2 = 4.14, p = .042) or an anatomical diagram (χ 2 = 12.33, p < .001) were significantly more likely to be correctly described, however, only 67.1% of referrals included a photograph and 53.9% included an anatomical diagram. Moreover, 100% of referrals that included triangulation were correctly described.

These findings highlight areas for targeted intervention to improve referral documentation.