Standard Form 515 (SF 515): Tissue Examination

Specimen

SPECIMEN SUBMITTED BY, DATE OBTAINED and SPECIMEN.

Brief clinical history

An open area whose label asks to include the duration of the lesion and its rapidity of growth for a neoplasm.

Diagnoses and findings

PREOPERATIVE DIAGNOSIS, OPERATIVE FINDINGS and POSTOPERATIVE DIAGNOSIS, with the signature, name and title of the signer.

Pathological report

NAME OF LABORATORY, three ACCESSION NO(S). boxes, and GROSS DESCRIPTION, HISTOLOGIC EXAMINATION AND DIAGNOSES, then the pathologist's signature, name and date.

Identification blocks

Hospital or medical facility, records maintained at, department or service of patient, relation to sponsor, sponsor's name and ID number (SSN or Other), patient's identification, register number and ward number.

The single page runs from the specimen at the top to the identification blocks at the bottom.

1. 1

   Identify the patient

   For typed or written entries, the form asks for the patient's name (last, first, middle), ID no. (SSN or other), sex, date of birth and rank or grade, plus register and ward numbers.

2. 2

   Describe the specimen

   Enter who submitted the specimen, the date it was obtained and the specimen itself.

3. 3

   Add history and diagnoses

   Write the brief clinical history, the preoperative diagnosis, the operative findings and the postoperative diagnosis.

4. 4

   Sign the clinical section

   The signer signs and prints their name and title in the boxes beside the postoperative diagnosis.

5. 5

   Complete the pathological report

   Enter the name of the laboratory, the accession numbers, and the gross description, histologic examination and diagnoses.

6. 6

   Pathologist signs and dates

   The report closes with the signature of the pathologist, the name of the pathologist and the date.

The form prints no step-by-step instructions. These steps follow its blocks.

• 

  SF516

  Medical Record - Operation Report

  26 fields, 1 page

• 

  OF522

  Medical Record - Request for Administration of Anesthesia and Performance of Operations and Other Procedures

  27 fields, 1 page

• 

  SF503

  Medical Record - Autopsy Protocol

  32 fields, 1 page

• 

  SF541

  Medical Record - Gynecologic Cytology

  48 fields, 1 page

• 

  SF513

  Medical Record - Consultation Sheet

  34 fields, 1 page

• The person submitting the specimen

  The first box reads SPECIMEN SUBMITTED BY, with a DATE OBTAINED box beside it.

• The signer of the clinical section

  Beside the postoperative diagnosis are lines for SIGNATURE, NAME OF SIGNER and TITLE OF SIGNER.

• The laboratory and pathologist

  The pathological report names the laboratory and ends with SIGNATURE OF PATHOLOGIST, NAME OF PATHOLOGIST and DATE.

• The patient and sponsor

  The patient is identified by name, ID no. (SSN or other), sex, date of birth and rank or grade. The form also asks for the relation to sponsor, the sponsor's name and the sponsor's ID number.

• The hospital or medical facility

  The bottom rows name the hospital or medical facility, where records are maintained, the department or service of the patient, and the register and ward numbers.

The form prints two signature areas and identification blocks for the patient and the facility. It does not say who fills in each block.

• Official GSA form page

  The agency’s own page for Form SF515.

• Blank PDF

  The official blank form, to print or fill by hand.

  Download blank PDF

No tool matches that search.