Appropriate Documentation of Normal Cervix on Pap Test
The appropriate phrase to document a normal cervix on a Pap test is "Negative for Intraepithelial Lesion or Malignancy" (NILM), which is the standardized terminology established by the Bethesda 2001 reporting system. 1
Standardized Bethesda Terminology
The Bethesda 2001 system requires laboratories to report cytopathology findings using specific standardized terminology, and NILM is the designated phrase for normal results. 1
- NILM explicitly indicates: No cellular evidence of neoplasia is present, regardless of whether other non-neoplastic findings exist (such as inflammation, reactive changes, or organisms). 1
- This terminology must be stated in the Interpretation/Result section of the Pap test report. 1
Complete Documentation Requirements
Beyond the NILM interpretation, proper documentation should include:
- Specimen adequacy: Document whether the specimen is "satisfactory for evaluation" and specifically note the presence or absence of endocervical/transformation zone component. 1
- Specimen type: Indicate whether conventional smear (Pap smear), liquid-based cytology, or other collection method was used. 1
- Quality indicators: Note any factors that may affect interpretation, such as partially obscuring blood or inflammation. 1
Common Pitfalls to Avoid
- Do not use vague terminology such as "normal cervix" or "benign findings" - these are not standardized Bethesda terms and may cause confusion in medical records and follow-up protocols. 1
- Do not confuse pelvic examination findings with Pap test results: Many patients erroneously believe a pelvic examination equals a Pap test, so documentation must clearly specify that cytology sampling was performed. 1
- Ensure CLIA-certified laboratory reporting: All cytopathology must be reported using Bethesda 2001 terminology by CLIA-certified laboratories to maintain quality standards. 1
Optional Non-Neoplastic Findings
When NILM is documented, the report may optionally include non-neoplastic findings such as:
- Reactive cellular changes associated with inflammation, radiation, or IUD 1
- Glandular cell status post-hysterectomy 1
- Atrophy 1
- Organisms (bacterial vaginosis, Candida, Trichomonas) 1
These additional findings do not change the NILM interpretation but provide clinically relevant information for patient management. 1