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At Cambridge College of Healthcare & Technology Bachelor of Health Information Management’s program, we prepare our students to understand both the clinical and regulatory aspects of healthcare. Medical record maintenance is more than a clerical task; it’s a cornerstone of professional accountability.
Healthcare providers are held to high standards, not only in delivering quality care but also in maintaining accurate, accessible medical records. Graduates of the Cambridge College of Healthcare & Technology’s Bachelor of Health Information Management program can help educate healthcare professionals, physicians, non-physician practitioners, hospitals, and suppliers, ensuring that they are in compliance with Medicare record-keeping regulations as the requirements can feel overwhelming.
Also, failure to follow documentation and access requirements doesn’t just create operational risk, it can lead to serious consequences, including revocation of Medicare enrollment.
The Solution: Understanding the Rules & Responsibilities
Medicare’s updated guidance outlines specific expectations for anyone who orders, certifies, refers, or prescribes Part A or B services, items, or drugs. Here’s what healthcare professionals need to know:
Documentation for Medicare Part A and Part B Services Must Be Maintained for at least 7 Years
From the date of service, all records must be kept—whether by the provider, facility, or entity responsible. This includes:
- Orders and prescriptions
- Face-to-face evaluations
- Notes from therapy or assessments
- Any documents supporting medical necessity
You’re Responsible for Providing Records Upon Request
Even if you rely on an employer, hospital, or third-party group to store records, you are still accountable when records are requested by Medicare or one of its contractors.
If you can’t produce the required documentation, you may face revocation under 42 CFR 424.535(a)(10).
Teaching Physicians, Residents, and Telehealth Providers Are Included
Whether you’re in a residency program or providing care remotely, the same rules apply. You must document presence (physical or virtual), include signatures, and avoid relying solely on macros or templates.
Records Must Be Complete, Accessible, and Timely
Partial submissions, missing signatures, or failure to respond within timelines may count as noncompliance. This could affect your ability to participate in the Medicare program in the future.
The Takeaway: Documentation is a Clinical and Ethical Responsibility
At Cambridge College of Healthcare & Technology’s Bachelor of Health Information Management program, we emphasize compliance and professionalism across all our programs. From Health Information Management to Nursing and beyond, students are taught that accurate documentation is a form of patient advocacy and a key component of risk management.
Whether you’re a future administrator, medical records coder, documentation improvement specialist, or clinician, understanding how to maintain and access medical records isn’t just about policy, it’s about protecting patients, providers, and the healthcare system as a whole.
Want to make a difference in healthcare? Start by mastering the systems that support it. Contact our Admissions team at Cambridge College of Healthcare & Technology to learn more about our career-focused programs today.