What's My Sign?
Keeping It Clean
Slide Into Those Medical Records
Name That Sign!
You Gotta Know!
100

Tenderness at a point one-third of the distance from the anterior superior iliac spine to the navel, a classic sign of appendicitis.

 What is McBurney’s point?

100

A staff member uses alcohol gel before and after taking vital signs on each patient during patient care. This infection prevention practice is being followed.

What is hand hygiene? 

100

This section of a SOAP note includes the patient's chief complaint and the description of symptoms in the patient's own words. 

What is the Subjective section?

100

A bluish discoloration of the skin and mucous membranes due to a lack of oxygen in the blood.

What is Cyanosis?

100

P.A.S.S. and R.A.C.E

What are the acronyms for Pull Aim Squeeze Sweep and Rescue Alarm Contain Evacuate?  

200

Bruising around the eyes, another sign of a basilar skull fracture.

What is Raccoon Eyes?

200

3 minute air dry time

What is the Cavi-wipe contact time?

200

Failing to obtain a patient's history of __________ is a common cause of medication error.  

What are allergies?

200

Swelling caused by excess fluid trapped in the body's tissues.

What is edema?

200

THIS is absolutely required during every patient encounter to avoid THIS estimated third leading cause of death in the United States. (two responses)

What are Medication reconciliation (medrec) and medication errors? 

300

Bruising behind the ears over the mastoid process, which may indicate a basilar skull fracture.

What is Battle Sign?

300

Is cleaned after each patient (no exceptions)

What is performed on the exam room chairs?

300

Uncommon _________ should be avoided in documentation as it can lead to misinterpretation; instead, write out he full term. 

Abbreviations

300

A yellowing of the skin and the whites of the eyes caused by an accumulation of bilirubin in the blood.

What is Jaundice?

300

These are two things that are absolutely required before performing a procedure on a patient. 

What are a consent form and a "time out"?

400

Pain in the left shoulder, which can indicate a ruptured spleen or other internal bleeding irritating the diaphragm.

What is Kehr's Sign?

400

A staff member dons gloves and mask before collecting a respiratory viral panel swab from a patient with URI symptoms. Which infection control principle applies?

What are standard and/or transmission-based precautions?

400

For new patients or patients not seen within a year, these are some required intake questions/screenings that must be assessed/updated. 

What are Health Literacy, Preferred method of education, complete past medical history, family medical history, social history?

400

Involuntary, rhythmic, jerking movements of the eyes.

What is Nystagmus?

400

These are the types of information found in the Safety Data Sheets (SDS) for the hazardous chemicals we could be exposed to.

What are product identification, hazard identification, first-aid measures, handling/storage requirements, exposure controls, physical/chemical properties, and emergency procedures.

500

A bluish discoloration around the umbilicus (belly button) that can indicate intra-abdominal bleeding.

What is Cullen's Sign?

500

A staff member, that is using transmission-based precaution, places the collected specimen into the lab biohazard bag and carries it to the lab with gloves on. This infection risk represents failure of this infection control principle.

What is cross-contamination prevention?

500

This specific section is where the provider documents the plan of care the provider and patient both agree with. **Hint: Used for diabetes management**

Patient Goals

500

Pinpoint, round spots that appear on the skin as a result of bleeding.

What is Petechiae?

500

Naval Medical Center San Diego prides ourselves in being an "HRO" which stands for __________ and this means that we are committed to _______________.

What is a High Reliability Organization that is committed to the highest quality and safest care for our patients?

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