Registered Dental Hygienist in Alternative Practice (RDHAP) Law and Ethics Practice Exam

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What should a hygienist do if they wish to identify themselves in patient records?

  1. Date the entries only

  2. Sign their name or ID next to the service performed

  3. Annotate records with their license number only

  4. Use initials without a signature

The correct answer is: Sign their name or ID next to the service performed

A hygienist identifying themselves in patient records should sign their name or ID next to the service performed. This practice is essential for maintaining clear and accurate documentation in a patient's health record. Proper identification not only ensures accountability for the services rendered but also aids in the continuity of care by allowing other healthcare providers to recognize who performed a service. In clinical settings, accurate documentation reflects the standard of care and legal expectations. Signing the record helps to distinguish which specific practitioner provided the service, thereby reducing any potential confusion about the treatment. Furthermore, it supports the integrity of the health record, which is vital in case of any audits, legal inquiries, or further clinical management. While dating entries, annotating records with a license number, or using initials without a signature may provide some level of reference, these methods lack the clarity and formality of a full name or identification. They may not provide sufficient transparency for future healthcare providers or may be insufficient to meet legal documentation standards. Thus, signing one's name or professional ID is the most appropriate and responsible action for hygiene professionals when documenting their involvement in patient care.