Marking for procedures

Updated July 1, 2026

I like to keep things simple in my procedures, and attempt to eliminate risk and redundancy for a graceful process. I often skip the step of using ink for skin marking altogether, relying upon indentations made by pressure with a blunt stylus (such as the “blank” smooth end of needle tubing) just prior to piercing. I prefer to confirm placement with the client with a laser pointer, in the mirror.

After cleaning the target site, I will sometimes do a non-sterile marking process prior to antisepsis when the client wants to see the exact placement, which I describe step by step in some detail below. Gentian Violet can also be sterilized as described in Resources below.

To avoid cross contamination, I use a completely separate non-sterile marking setup and a no-touch sterile method for antiseptic prep such as long handled sterile swabs to apply the antiseptic.

A simple aseptic skin prep and marking process:

1. Don mask.
2. Clean hands.
3. Don new non-sterile medical exam gloves.
4. Pick up items needed for cleaning, marking, and antisepsis.
   *This consists of a sufficient number of packages of antiseptic cleaning agent, sterile gauze, sterile swabs and a clean single use non-toxic marking implement.

   Alternately if you use liquid gentian violet:

   1. Open packages for cleaning gauze.
   2. Dispense a drop of gentian violet and marking implement on to sterile field of the opposite inside panel of the package from the gauze.
   3. Remove gloves.
   4. Clean hands.
   5. Don new non-sterile exam gloves.
   6. Pick up cleaning gauze and marking implement, and sealed sterile swabs.
   7. Dip to apply sufficient gentian violet to tip of implement.
5. Dispense antiseptic cleaning product onto sterile gauze using a no-touch method.
6. Clean client area.
7. Mark cleaned area.
8. Measure if needed, and adjust marks.
9. Allow client to confirm marks.
10. Position client.
11. Apply antiseptic surgical skin preparation agent using a no-touch technique with a long handled sterile swab according to product instructions for use.
12. Remove gloves.
13. Clean hands.
14. Open sterile glove package, then Statim sterilization cassette or package containing sterile items needed for procedure.
15. Clean hands.
16. Don sterile gloves.
17. Open instrument organizer tray inside Statim sterilization cassette.

    Alternately if needed:

    1. Move the sterile tray to the sterile field of the sterile glove inner wrapper.
    2. Close Statim sterilization cassette with a no-touch elbow or sterile barrier technique.
    3. Open sterile organizer tray.
18. Perform tissue manipulation and alignment.
19. Make indentations on piercing entry and exit sites with blunt end of sterile needle or post of sterile jewelry to assess precise marks.
20. Perform piercing and jewelry insertion procedure.
21. Remove residue with sterile gauze or sterile saline wipe if needed.

For complicated sets of piercings, I do sterile marking after cleaning, antisepsis and donning sterile gloves (step 17) with a single use sterile surgical marker, and make use of the included ruler for precisely matched placements. I keep a hand mirror within reach for clients to confirm if needed without having to change position.

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Bonus

New Research

What About the Marker Itself?

A study published last year in Cureus found that site marking pens may be vehicles for bacterial colonization and transmission even after surgical site preparation with povidone-iodine.

AORN’s Patient Skin Antisepsis Guideline addresses this issue. It recommends that facilities assemble interdisciplinary teams to select surgical site markers based on their effect on the sterility of skin antisepsis, and that any markers used should not promote bacterial growth or transmit infection.

“There is no recommendation on what type of material or pen should be used to mark the site, but it should be made at or near the procedure site and be visible after surgical skin antisepsis and draping,” says Lisa Spruce, DNP, RN, CNS-CP, CNOR, ACNS, ACNP, FAAN, senior director of evidence-based perioperative practice with AORN. “Most facilities use an indelible marker, but this is not the sole means of marking the site.” Indeed, the AORN recommendation is that marking the site with a nonsterile permanent marker is a safe practice. The guideline cites two quasi-experimental studies that evaluated the effect of site marking on the sterility of skin antisepsis. Both concluded that skin marking with a nonsterile permanent marker did not affect the sterility of skin antisepsis with povidone-iodine, as evidenced by no culture growth at the treated areas.

AORN cites an additional study that suggests that single-use marking pens be considered when a known infection risk exists, such as a procedure involving implants.

Returning to the study referenced at the start of this sidebar, what went wrong? Simply put, don’t reuse site marking pens. “We would never recommend that a marking pen be used repeatedly from patient to patient,” says Dr. Spruce. “Marking pens need to be single-use and discarded after marking the patient.”

One final bit of insight from Dr. Spruce: Only use pens designed for the purpose of surgical site marking — never a sharpie or personal ink pen. While that sounds obvious, she says this sometimes happens in the field.

—Joe Paone

https://www.aorn.org/outpatient-surgery/article/standards-of-surgical-site-marking