Cytopathology Report (Cervicovaginal Pap Test)

Patient Name: [Patient full name]

MRN/Accession: [Medical record number and/or ordering accession identifier]

Date of Birth: [Date of birth]

Sex: [Sex]

Ordering Clinician: [Ordering clinician name and credentials]

Submitting Facility: [Submitting facility name] (Only include if different from performing lab)

Performing Laboratory: [Performing laboratory name, address/location]

Report Date: [Report date]

Report Status: [Final / Preliminary / Corrected / Amended]

Accession Number: [Laboratory accession number]

Specimen ID: [Specimen identifier(s)] (Include only if multiple specimens)

Test Performed: Cervicovaginal cytology (Pap test) — [Conventional smear / Liquid-based cytology]

Specimen Details

(For multiple specimens, create separate labeled blocks: Specimen A, Specimen B, etc.)

• Specimen source: [Cervix / Cervicovaginal / Vaginal cuff / Vaginal post-hysterectomy] [Site qualifiers if provided]
• Specimen type/preparation: [Conventional smear / Liquid-based cytology with method/platform]
• Collection date: [Collection date]
• Received date: [Received date] (Include if provided)
• Specimen condition: [Acceptable / Describe any labeling, leakage, fixation, or transport issues] (Only include if issues present or specimen rejected)
• Disposition: [Processed / Specimen rejected—state reason] (If rejected, note whether recollection is requested)

Clinical Information

(Display requisition-provided data. If no clinical information was provided, state only: "Clinical information: Not provided" and omit the list below.)

• LMP or menopausal status: [Last menstrual period date / Postmenopausal]
• Prior abnormal cytology/histology: [Relevant prior results and treatments if provided]
• History of CIN2+: [Yes / No]
• Hysterectomy status: [Cervix present / Cervix absent]
• Pregnancy/postpartum: [Pregnant / Postpartum] (Include only if applicable)
• Immunosuppression: [Yes — specify if known] (Include only if applicable)
• Indication: [Routine screening / Follow-up of abnormality / Post-treatment surveillance]

Specimen Adequacy

Satisfactory for evaluation. Transformation zone component: [Present / Absent / Not applicable]. Quality indicators: [None / Partially obscuring blood / Inflammation / Poor fixation / Thick areas / Excess lubricant].

— OR —

Unsatisfactory for evaluation. [Specimen rejected/not processed / Specimen processed and examined, but unsatisfactory]. Reason: [Insufficient squamous cellularity / >75% of epithelial cells obscured by blood/inflammation / Air-drying artifact / Other]. (If epithelial abnormality is identified despite limitations, report as satisfactory with limitation statement.)

General Categorization

(Optional section; include only if used by the laboratory.)

[Negative for intraepithelial lesion or malignancy (NILM) / Epithelial cell abnormality — squamous / Epithelial cell abnormality — glandular / Other]

Interpretation/Result

Primary interpretation: [Negative for intraepithelial lesion or malignancy (NILM) / Atypical squamous cells of undetermined significance (ASC-US) / Atypical squamous cells—cannot exclude HSIL (ASC-H) / Low-grade squamous intraepithelial lesion (LSIL) / High-grade squamous intraepithelial lesion (HSIL) / Squamous cell carcinoma / Atypical glandular cells (AGC) — endocervical/endometrial/NOS / Atypical glandular cells, favor neoplastic / Endocervical adenocarcinoma in situ (AIS) / Adenocarcinoma — endocervical/endometrial/extrauterine/NOS / Other — specify]

For NILM results (include if applicable):

• Non-neoplastic findings: [Reactive cellular changes / Atrophy / Radiation effect / IUD-associated changes]
• Organisms: [Trichomonas vaginalis / Fungal organisms morphologically consistent with Candida species / Shift in flora suggestive of bacterial vaginosis / Bacteria morphologically consistent with Actinomyces species]

Ancillary Testing

(Include this section when HPV or other adjunctive testing was performed or is pending. Omit if not applicable.)

• High-risk HPV: [Detected / Not detected / Indeterminate / Quantity not sufficient]
• HPV genotyping: HPV 16: [Detected / Not detected]; HPV 18/45: [Detected / Not detected]; Other high-risk types: [Detected / Not detected] (Include if genotyping performed)
• HPV test status: [Final / Pending — addendum to follow]
• Computer-assisted screening: [Device/software name] — [Output category] (Include if applicable)

Comment

[Brief explanatory comment] (Use for: explaining adequacy limitations; correlation with HPV testing; explanation of "Other" findings such as benign-appearing endometrial cells; significant limitations. Keep brief; avoid detailed management algorithms. Omit section if no comment needed.)

Pathologist Sign-Out

Signed by: [Name, credentials of cytopathologist or authorized technical supervisor]

Electronically signed: [Date/time of signature]

Correction/Amendment

(Include only if Report Status is Corrected or Amended.)

Report label: [Corrected Report / Amended Report]

Date/time of correction: [Date/time]

Description of change: [Brief statement of what changed]