Thyroid Fine-Needle Aspiration Procedure Note

Date/Time: [Procedure date and start time]

Patient: [Full name] | [MRN] | [DOB]

Location: [Clinic / radiology suite / bedside]

Procedure: [Ultrasound-guided FNA of (laterality/structure) with number of targets]

Operators: [Primary operator, credentials] [; Assistant if applicable] [; Cytotechnologist/Pathologist if on-site adequacy performed]

Indication

[Clinical indication for biopsy, including guideline-based criteria or clinical concern; relevant prior imaging or cytology with dates if repeat procedure; pertinent history only if directly relevant to the indication]

Pre-Procedure Review

• Allergies: [List allergies to local anesthetics, antiseptics, latex / NKDA]
• Antithrombotic status: [None / list agents with last dose and whether held]
• Relevant labs: [Platelets, INR, aPTT with values] (Only include if obtained)
• Sedation: [None / minimal / moderate]

Consent

[Written / verbal] informed consent obtained. Procedure, risks (bleeding/hematoma, pain, infection, nondiagnostic result requiring repeat, rare airway compromise), and alternatives (observation, repeat imaging, surgery) were discussed. [If consent exception, document authorization.]

Time-Out

Time-out performed. Patient identity verified using two identifiers, correct procedure and site/laterality confirmed. (This statement is required. If time-out was not performed, explicitly document the exception and reason.)

Target Description

Target	Structure	Location	Size	Key Features	Sampling Rationale
[1]	[Thyroid nodule / Lymph node]	[Lobe and pole / neck level]	[Length × width × depth cm]	[Composition, echogenicity, margins, calcifications, vascularity]	[High-suspicion pattern / prior AUS-FLUS / suspicious node / growth]
[2]	[Structure]	[Location]	[Size]	[Key features]	[Rationale]

(If recent diagnostic ultrasound report exists, reference by date and keep descriptors minimal. For lymph node targets with Tg/calcitonin washout, document collection method and diluent volume.)

Technique

[Patient positioning]. [Skin preparation and antiseptic]. Sterile technique with drape and probe cover. [Local anesthesia: agent, concentration, volume / no local anesthesia used]. Under continuous real-time ultrasound guidance, a [25G / 27G] needle was advanced to target using [transisthmic / longitudinal] approach. Sampling performed using [capillary / suction] technique.

Pass Summary

Target	Needle Gauge	Passes	Specimen Preparation	ROSE Result
[1]	[25G / 27G]	[#]	[Air-dried smears / alcohol-fixed smears / liquid-based cytology rinse]	[Adequate after pass # / Additional pass requested / Not performed]
[2]	[Gauge]	[#]	[Specimen prep]	[ROSE result]

Specimens

[Number and type of specimens collected]. Labeling confirmed with patient identifiers, target ID, laterality, site, and date. Sent to cytopathology. [Special studies if ordered: molecular testing, flow cytometry, Tg/calcitonin washout]

Hemostasis

Manual compression applied. [Post-procedure ultrasound: no hematoma identified / hematoma size and characteristics]. Estimated blood loss minimal.

Complications and Tolerance

[Patient tolerated procedure well / describe symptoms: pain, anxiety, vasovagal response]. [No immediate complications / describe complication with size/extent and management]. (This section must be explicitly completed; do not omit.)

Disposition

[Observed for duration / discharged home] in [stable condition]. [Antithrombotic resumption plan / defer to ordering clinician].

Procedure status: [Completed as planned / modified: reason / aborted: reason] (Include only if not completed as planned)

Follow-Up

Results to be communicated via [phone / portal / follow-up visit] within [expected turnaround]. [Responsible clinician] will contact patient. If nondiagnostic or indeterminate: [repeat FNA / molecular testing]. If suspicious or malignant: [surgical referral pathway].

Images archived: [Yes / No] (Include only if applicable to local documentation standards)