EBUS-TBNA Procedure Note

Date/Time: [Procedure start time] – [Procedure end time]

Location: [Bronchoscopy suite / OR / ICU bedside / other]

Patient: [Patient name, MRN, DOB]

Bronchoscopist: [Primary operator name and credentials]

Anesthesia: [Anesthesia provider name], [general anesthesia / MAC / deep sedation] (Medication administration and physiologic monitoring documented in anesthesia record.)

Cytopathology/ROSE: [Cytopathologist name and credentials / ROSE not available]

Procedures Performed: [List all procedures performed, e.g., flexible bronchoscopy, EBUS survey of mediastinum/hila, EBUS-TBNA of stations X/X/X, BAL, EUS-B FNA, endobronchial biopsy as applicable]

Indication: [Single-sentence clinical reason for procedure]

Pre-Procedure

• Informed consent obtained from [patient / surrogate]. Risks, benefits, and alternatives discussed; questions answered.
• Time-out completed per Universal Protocol.
• Anticoagulation/antiplatelet status: [Agent(s), last dose, peri-procedural management]
• Baseline oxygen requirement: [Device and flow/FiO2]

Airway Examination

[Narrative airway survey findings] (State whether airways were normal or describe abnormalities including endobronchial lesions, extrinsic compression, mucosal changes, or secretions. If complete airway exam was not performed, state the limitation and reason.)

EBUS Approach

[Systematic staging survey / Targeted exam]: [Brief description of sampling strategy] (If systematic, note intended sampling order such as contralateral N3 → ipsilateral N2 → N1. If targeted, state reasoning such as diagnostic intent for known abnormality or patient factors limiting exam.)

Lymph Node Stations Assessed

(Use IASLC nodal station nomenclature with laterality. For staging cases, document stations 4R, 4L, and 7 at minimum, even if normal or not sampled.)

• Station [number with laterality]: [Short-axis size in mm]

  Sampled: [Yes / No] (If no: [Less than 5 mm / Not indicated / Technically inaccessible / Time limitation / other])

• (Repeat for each station visualized.)

EBUS-TBNA Sampling Details

(Create separate entry for each sampled station.)

• Station [number with laterality]: [Target node short-axis size in mm]

  Needle: [21G / 22G / 25G] | Passes: [Number]

  Specimen: [Smears (air-dried / alcohol-fixed) / Liquid-based cytology / Cell block / Needle rinse] (List all specimen types prepared with medium if applicable.)

  Ancillary: [Flow cytometry / Microbiology (AFB, fungal, bacterial) / Molecular or NGS panel / PD-L1 / None] (Specify specimen allocation.)

  ROSE: [Adequate lymphoid tissue / Inadequate / Not performed]; [Preliminary interpretation] (If performed, clearly label interpretation as preliminary with final diagnosis pending pathology. If not performed, state "Not performed" and omit adequacy assessment.)

• (Repeat for each station sampled.)

Specimen Labeling

All specimens labeled with station number, laterality, and specimen type. Submitted to: [Cytology / Surgical pathology / Microbiology / Flow cytometry] (List all applicable destinations.)

Complications

[No immediate complications / Description of complications] (If complications occurred, document type (bleeding, hypoxemia, bronchospasm, pneumothorax, arrhythmia), severity, interventions performed, and estimated blood loss if applicable. For pneumothorax assessment, state "No immediate clinical evidence of pneumothorax" only if clinically assessed; do not state definitively ruled out unless imaging confirmed.)

Patient tolerance: [Tolerated procedure well / Description of hemodynamic or respiratory instability]

Post-Procedure Status

• Airway: [Extubated / Remained intubated]
• Recovery location: [PACU / ICU / Endoscopy recovery / other]
• Oxygen at handoff: [Device and flow/FiO2]
• Disposition: [Home / Admitted to service and level of care]
• Post-procedure orders: [Chest radiograph ordered / Routine monitoring / other] (Include only if clinically indicated.)

Impression

• [Summary of stations sampled with total passes]
• [ROSE summary, labeled preliminary, with final pathology pending] (Omit if ROSE not performed.)
• [Key airway findings relevant to diagnosis or staging] (Omit if normal airway exam.)
• [Significant limitations affecting exam reliability] (Omit if none.)

Plan

• Pathology results pending; expected turnaround [timeframe]. Results to be followed by [responsible party/service].
• Next steps contingent on results: [Oncology referral / Surgical staging if negative / Repeat sampling if nondiagnostic / other]
• [Urgent communications: Preliminary findings communicated to whom and when] (Include only if applicable.)
• Follow-up: [Appointment or contact plan with timing]

(General instruction: If information was not performed or assessed, document explicitly as "Not performed," "Not assessed," or "Not available." Do not infer nodal involvement, specimen adequacy, or diagnoses unless explicitly stated by operator or ROSE personnel.)