Development of a standardized documentation template for neck ultrasonography in oral and maxillofacial surgery: a technical note

Neck ultrasonography (US) is widely used for the evaluation of cervical lymph nodes, thyroid abnormalities, salivary gland disease, and other superficial neck lesions. However, variability in documentation may hinder consistent recording and longitudinal comparison, particularly in oral and maxillofacial surgery (OMFS), where repeated outpatient examinations are frequently performed. We developed a standardized documentation template for neck US, intended for future implementation within an electronic medical record system and tailored to routine OMFS practice. Three OMFS clinicians selected the template items through review of established guidelines and existing neck US reporting practices. The proposed template consists of six modules covering general examination information, cervical lymph nodes, diffuse thyroid findings, thyroid nodules, salivary gland assessment, and anatomical lesion mapping. Established sonographic terminology and reporting frameworks were incorporated where applicable, together with fields for previous measurements, procedural history, and interval change. The modular structure was designed to accommodate both comprehensive and focused neck US examinations within the routine OMFS outpatient workflow. This integrated format may provide a practical framework for standardized documentation and longitudinal comparison. Future clinical studies are required to evaluate its usability, reproducibility, and clinical value.