HIPAA Security Rule
Policies and Procedures

HIPAA Security Rule 164.316(b)(1): Documentation (Standard)

Maintain the policies and procedures and a written or electronic record of any required action, activity, or assessment. NIST recommends document management platform with controlled retention.

Maintained by Gerard BlokdykVerified against the published standard Control text last updated

What else in your programme already covers this

This control maps to 77 controls across 22 other frameworks. If you already hold one of them, the evidence you collected for it is the starting point here rather than new work.

PCI DSS 4.0 · 17 controls

  • 1.2.3 1.2.3 Accurate network diagram of CDE connections
  • 1.2.5 1.2.5 Allowed services, protocols and ports justified
  • 11.4.1 11.4.1 Penetration testing methodology defined and implemented
  • 12.1.1 12.1.1 Overall information security policy established and disseminated
  • 12.3.2 12.3.2 Targeted risk analysis for each customized-approach requirement
  • 12.3.3 12.3.3 Cryptographic cipher suite and protocol inventory reviewed annually
  • 12.4.2.1 12.4.2.1 Documentation of quarterly operational reviews
  • 12.8.4 12.8.4 Annual monitoring of TPSP compliance status
  • 2.1.1 2.1.1 Requirement 2 policies and procedures governed
  • 2.1.2 2.1.2 Requirement 2 roles and responsibilities assigned
  • 4.1.2 4.1.2 Requirement 4 roles and responsibilities assigned
  • 5.3.4 5.3.4 Anti-malware audit logs enabled and retained
  • 6.1.1 6.1.1 Requirement 6 policies and procedures maintained and communicated
  • 9.1.2 9.1.2 Requirement 9 roles and responsibilities assigned
  • 3.1.1 3.1.1 Requirement 3 policies and procedures maintained and in use
  • 6.3.2 6.3.2 Inventory of bespoke software and components
  • 8.1.2 8.1.2 Requirement 8 roles and responsibilities assigned

NIST SP 800-53 Rev 5 · 8 controls

  • NIST-CSF-GV.OC-03 Legal, regulatory, and contractual requirements regarding cybersecurity - including privacy and civil liberties obligations - are understood and managed
  • NIST-CSF-GV.PO-01 Policy for managing cybersecurity risks is established based on organizational context, cybersecurity strategy, and priorities and is communicated and enforced
  • NIST-CSF-GV.PO-02 Policy for managing cybersecurity risks is reviewed, updated, communicated, and enforced to reflect changes in requirements, threats, technology, and organizational mission
  • NIST-CSF-ID.IM-04 Incident response plans and other cybersecurity plans that affect operations are established, communicated, maintained, and improved
  • NIST-CSF-PR.PS-04 Log records are generated and made available for continuous monitoring
  • NIST-CSF-RS.AN-06 Actions performed during an investigation are recorded, and the records' integrity and provenance are preserved

SOC 2 · 5 controls

  • SOC2-CC4.2 CC4.2 Evaluating and communicating control deficiencies (COSO principle 17)
  • SOC2-CC5.3 CC5.3 Deploying controls through policies and procedures (COSO principle 12)
  • SOC2-CC6.5 CC6.5 Protecting data on assets until disposal
  • SOC2-P6.2 P6.2 Record of authorised disclosures
  • SOC2-P6.3 P6.3 Record of unauthorised disclosures and breaches

CIS Controls v8 · 4 controls

  • CIS-2.1 Establish and Maintain a Software Inventory
  • CIS-6.6 Establish and Maintain an Inventory of Authentication and Authorization Systems
  • CIS-8.1 Establish and Maintain an Audit Log Management Process
  • CIS-8.10 Retain Audit Logs

ISO 27701:2019 · 4 controls

  • 5.5.5 Documented information
  • 6.3 Organization of information security
  • 6.9.1 Operational procedures and responsibilities
  • 8.2 Conditions for collection and processing

FedRAMP High · 3 controls

  • AT-4 Training Records
  • PL-2 System Security and Privacy Plans
  • SI-12 Information Management and Retention

FedRAMP Moderate · 3 controls

  • AT-4 Training Records
  • PL-2 System Security and Privacy Plans
  • SI-12 Information Management and Retention

ISO 22301:2019 · 3 controls

  • 7.5 Documented information
  • 7.5.1 General
  • 7.5.3 Control of documented information

ISO 27001:2022 · 3 controls

  • 5.1 Policies for information security
  • 5.33 Protection of records
  • 5.37 Documented operating procedures

ISO 27002:2022 · 3 controls

  • 5.1 Policies for information security
  • 5.33 Protection of records
  • 5.37 Documented operating procedures

NIST SP 800-161 Rev 1 · 3 controls

NIST SP 800-171 Rev 3 · 3 controls

ISO/IEC 42001:2023 · 2 controls

  • 7.5 Documented information
  • 7.5.3 Control of documented information

APRA CPS 234 · 1 control

  • CPS234-19 Information Security Policy Framework
  • AUCDR-IS-STEP1 Step 1 - Define and implement security governance for CDR data
  • MYHR-SBD-3 Record keeping for sharing with the My Health Record system

C5 (Germany) · 1 control

  • C5-SP-01 Documentation, communication and provision of policies and instructions
  • CFTC-SS-20 Production of System Safeguards Books and Records

CMMC 2.0 · 1 control

NIST SP 800-172 · 1 control

  • 3.11.4e Security Solution Rationale Document

Every mapping shown was judged rather than inferred from wording similarity, and the ones that failed review are published too. See the coverage reports and what was rejected.

Other controls in Policies and Procedures

You are reading one control. How much of HIPAA Security Rule have you already done?

HIPAA Security Rule 164.316(b)(1) is one control. If you already hold one of the frameworks below, a reviewed crosswalk already says how much of HIPAA Security Rule your existing evidence covers. Hold ISO 27001:2022 and 53 of 67 HIPAA Security Rule controls already carry evidence.

Each report names every control your existing framework evidences, every one it does not, the reasoning behind each claim, and the claims that were argued against and rejected. 64 were rejected on the ISO 27001:2022 pair alone.

Query this from an agent

The graph holds this control, the 77 it maps to, and the evidence behind each claim, over MCP and REST.