Sentinel Lymph Node Mapping Procedure Note

Patient: [Patient name], [MRN or DOB]

Accession/Encounter: [Accession number]; [Encounter ID]

Date: [Procedure date]

Injection Time: [HH:MM with timezone]

Imaging Time: [Start time] – [End time]

Facility/Location: [Facility name], [Department]

Interpreting Physician: [Physician name, credentials]

Technologist/Injector: [Name(s) and role(s)]

Indication

[Primary diagnosis and tumor type]; [Anatomic primary site with explicit laterality and subsite]. [Operative intent: preoperative sentinel node localization for planned SLNB, surgical date if known]. [Pertinent prior interventions affecting lymphatic drainage, or none]. (If primary site or laterality is uncertain, explicitly document this safety-critical gap and how it was reconciled. Do not imply nodal metastasis status from this procedure.)

Technique

Radiopharmaceutical: [Agent name and radionuclide]. Administered activity: [Total dose in MBq/mCi] in [Total volume], given as [Number] injections of [Per-injection dose] in [Per-injection volume] each. Route/depth: [Route]. Injection distribution: [Pattern and anatomic reference relative to lesion or biopsy scar], [explicit laterality and subsite]. Immediate complications: [None, or describe extravasation/leakage/contamination with management and impact on imaging].

Imaging protocol: [Modalities performed] at [Timing post-injection]. Projections/fields of view: [Views obtained]. Patient positioning: [Position and rationale for surgical correlation]. External markers: [None, or type and placement]. (Include only modalities and acquisitions actually performed.)

Findings

Lymphatic drainage: [Channels visualized yes/no]; [Directionality and course]; [Unilateral/bilateral pattern]. (If shine-through, contamination, prior surgery, or other factors limit evaluation, describe and note mitigation.)

• SLN #1: [Basin/station], [side], [location relative to landmarks], [depth estimate], [uptake intensity], [order of appearance if relevant]
• SLN #2: [Basin/station], [side], [landmarks], [depth], [uptake intensity]
• (Add additional SLNs as needed; if multiple nodes cluster at one hotspot, state estimated count)

Additional nodes: [Second-echelon or interval nodes if identified, clearly distinguished from SLNs]

Study limitations: [None, or describe limiting factors, mitigation steps, and impact on operative planning]

Impression

• Total SLNs localized: [Number]
• Drainage summary: [Unilateral/bilateral]; basins involved: [List]; [Any unexpected drainage]
• Localization: [SLN-specific basin, side, and landmark relationships for surgical guidance]
• Skin marking: [Performed/not performed with reason]; [Method, patient position, mark locations linked to SLN numbers]
• Limitations/cautions: [Near-field nodes, poor visualization, probable clusters, or other factors affecting intraoperative localization]
• Communication: [Surgeon name/role] notified via [Method] on [Date/time]; [Summary of information conveyed]; [Images/map provided to OR: yes/no]

(If any required information is unavailable, state explicitly with reason. Safety-critical elements: laterality, injection site, administered activity, injection and imaging times, SLN count and locations, and surgeon communication.)