CMPT01/F/10/2009: Gram Smear Report Form 
Laboratory Name: Laboratory No:
Gram Smear Speciment Number: Source/Site:
Date Specimen Received: Date Specimen Reported:

This Table is for reporting the CELLULAR COMPONENT in ALL Smears EXCEPT Sputum.
Cell Type Count per oil immersion field
based on at least 10 fields  

Interpretation: 1+, 2+, 3+, 4+
Based on Laboratory's internal
Interpretation guidelines  

1. Neutrophils    
2. Epithelial cells    
3.     

This Table is for reporting the CELLULAR COMPONENT  in SPUTUM Smears ONLY.
Cell Type   Count per low-power field  

Interpretation: 1+, 2+, 3+, 4+ Based on Laboratory's internal interpretation guidelines-include comment below if applicable or check one of the boxes below.
1. Epithelial cells    
2. Neutrophils    
3.    

Please check if your report would state:
"Culture pending/or culture results to follow." (suitable for culture)
"Final report-sample not suitable for culturing."

This Table is for reporting the BACTERIAL COMPONENT in ALL smears.

BACTERIAL Gram Morphology 
No organisms seen

Count per oil immersion field based on at least 10 fields  

Interpretation: 1+, 2+, 3+, 4+
Based on Laboratory's internal interpretation guidelines - include comment below if applicable

1.     
2.    
3.    
4.     
COMMENTS - This is a free-text box. Please provide the EXACT wording as it would appear on a clinical report.  Include all interpretive comments that are part of your clinical Gram stain report. Please attach an additional page if necessary.

 

 
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