Documentation of Suspected Melanoma in Primary Care
No, you should not diagnose the lesion definitively as "melanoma" in your medical note; instead, document it as "lesion suspicious for melanoma" or "pigmented lesion concerning for possible melanoma" pending specialist evaluation and histopathological confirmation. 1
Rationale for Appropriate Documentation
Why Definitive Diagnosis Should Be Avoided
- Melanoma diagnosis requires histopathological confirmation - The definitive diagnosis can only be established after full-thickness excisional biopsy with pathological examination that includes Breslow thickness, Clark level, ulceration status, and surgical margin assessment 1, 2, 3
- Clinical assessment alone has limited accuracy - Even experienced clinicians achieve diagnostic accuracy of only approximately 85% based on clinical examination alone, meaning 15% of clinically suspected melanomas are benign lesions 1
- Premature labeling creates medical-legal and insurance complications - Documenting a definitive diagnosis without histopathological proof can create problems with insurance coding, patient anxiety, and potential liability if the lesion proves benign 4
Appropriate Documentation Language
Use descriptive terminology that conveys clinical suspicion without premature diagnosis:
- "Pigmented lesion suspicious for melanoma"
- "Atypical pigmented lesion concerning for possible malignant melanoma"
- "New skin lesion with features suggestive of melanoma" 1
Document specific concerning features you observe using the major and minor signs:
- Major signs: Change in size, change in shape, change in color, diameter ≥7 mm 1
- Minor signs: Inflammation, sensory change, crusting or bleeding 1
Your Immediate Actions
Urgent Referral Requirements
- Refer urgently to a dermatologist or surgeon/plastic surgeon with expertise in pigmented lesions - Systems should enable the patient to be seen within 2 weeks of receipt of your referral letter 1, 2
- Clearly state in your referral letter which specific features prompted the referral and the patient's degree of concern 1
What NOT to Do in Primary Care
- Do not perform shave or punch biopsies - These make pathological staging impossible and are not recommended for suspected melanoma 1
- Do not perform incisional biopsies - There is no place for incisional biopsy of suspected melanoma in primary care 1
- Do not attempt excision yourself unless you can perform full-thickness excision with 2-5 mm margins and subcutaneous fat, which should be done by specialists 1, 2, 5
Common Pitfalls to Avoid
- Avoid using definitive diagnostic terminology ("melanoma," "malignant melanoma") before histopathological confirmation 3, 4
- Do not delay referral while waiting for additional testing or photography - urgent specialist evaluation takes priority 1, 2
- Do not reassure the patient that it's "probably nothing" even if trying to reduce anxiety - maintain appropriate clinical concern while explaining the need for specialist evaluation 1