Dates and source of specimen
DATE OBTAINED, LMP FIRST DAY and DATE RECEIVED IN LABORATORY, then boxes for the source: combined cervix and vagina, cervix, vagina or other (specify).
SF541
Medical Record - Gynecologic Cytology
- Agency
- GSA
- Revision
- Rev. 11/1977
- Fillable fields
- 48
- Pages
- 1
- Official source
- GSA form page
- Checked
- October 20, 2026
Standard Form 541 (SF 541): Gynecologic Cytology
Standard Form 541 (SF 541), Gynecologic Cytology, is a one-page medical record printed as STANDARD FORM 541 (REV. 11-77). Its footer says Prescribed by GSA and ICMR, FPMR 101-11.806-8, and GSA hosts a copy in its forms library, where it is listed as Medical Record - Gynecologic Cytology.
Section I holds the clinical data, to be completed by the examining installation: the dates, the source of the specimen, age, pregnancy, gravida and para, any previous abnormal cytologic examination, the clinical history, the physical examination and the submitting facility. Section II holds the cytologic findings from the reporting installation only: the laboratory, yes or no findings, a maturation index, comments and recommendations, and the pathologist's signature. The bottom row identifies the patient.
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What's on SF 541
Patient history
AGE, PREGNANCY yes or no, GRAVIDA, PARA, and PREVIOUS ABNORMAL CYTOLOGIC EXAMINATION, yes (give date) or no.
Clinical history and examination
CLINICAL HISTORY (Surgery, drugs, hormones, radiation, etc.) and PHYSICAL EXAMINATION (Pelvic findings, etc.), then the submitting facility, signature and title, and accession number.
Cytologic findings
Yes or no boxes for granulocytes, leptothrix, trichomonas, candida and endocervical cells, a SCREENED BY box, and a MATURATION INDEX with parabasals, intermediates and superficials.
Comments and pathologist
COMMENTS AND RECOMMENDATIONS, then PATHOLOGIST'S SIGNATURE, TITLE and DATE.
Patient identification
PATIENT'S IDENTIFICATION (name, grade, rank, rate, hospital or medical facility), REGISTER NO. and WARD OR CLINIC.
The single page has two sections and a patient identification row.
How to fill out SF 541
- 1
Identify the patient
Enter the patient's name (last, first, middle), grade, rank, rate and hospital or medical facility, plus the register number and ward or clinic.
- 2
Record the specimen
Enter the date obtained and the first day of the LMP, and check the source of the specimen. The date received in laboratory sits beside them.
- 3
Add the clinical data
Fill in age, pregnancy, gravida, para, any previous abnormal cytologic examination with its date, the clinical history and the physical examination.
- 4
Sign as the submitting facility
Name the facility submitting the specimen, add the signature and title, and enter the submitting facility accession number.
- 5
Report the cytologic findings
The reporting laboratory enters its name and accession number, checks yes or no for each finding, notes who screened it and fills in the maturation index.
- 6
Pathologist signs and dates
Write the comments and recommendations, then the pathologist signs and adds a title and date.
The form prints no step-by-step instructions. These steps follow its sections.
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Where it goes and what the form says
Where it goes
The PDF prints no filing address. It is labeled Medical Record. Section I is completed by the examining installation and Section II by the reporting installation.
Prescribing note
The footer says Prescribed by GSA and ICMR, FPMR 101-11.806-8.
Edition
The footer prints STANDARD FORM 541 (REV. 11-77). GSA's page lists the current revision date as 11/1977.
Related forms
Who completes SF 541?
The two section headings say which installation completes each part. The form prints no filing address.
Official sources and the blank
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Questions about Form SF541
Who issues SF 541?
The footer says Prescribed by GSA and ICMR, FPMR 101-11.806-8. GSA hosts a copy in its forms library, printed as STANDARD FORM 541 (REV. 11-77).
Who completes each section of SF 541?
The form says Section I, clinical data, is to be completed by the examining installation, and Section II, cytologic findings, is from the reporting installation only.
What does the source of specimen block ask?
It has boxes for combined cervix and vagina, cervix, vagina, and other with space to specify.
Who signs SF 541?
Section I has a signature and title box for the submitting facility. Section II has the pathologist's signature, title and date.
What patient details does SF 541 ask for?
The patient's name (last, first, middle), grade, rank, rate and hospital or medical facility, plus a register number and ward or clinic. Section I also asks for age, pregnancy, gravida and para.