Enterprise Imaging Archive Clean Desk Policy Checklist

An enterprise imaging archive clean desk policy helps protect patient information wherever imaging data is handled: in reading rooms, at PACS workstations, in archive operations, and on removable media. Use this checklist to turn everyday practices into clear staff responsibilities and repeatable security controls.

Secure Paper Records and Imaging Media

• Store printed image reports, worklists, labels, and documents containing patient identifiers in locked drawers or approved secure areas when not in use.
• Collect printouts promptly from shared printers and copiers. Confirm that documents are intended for you before taking them.
• Do not leave CDs, DVDs, USB drives, portable hard drives, or other media containing DICOM image data unattended or in unlocked areas.
• Use only organization-approved media and secure medical image exchange methods. Track media that is received, transported, loaned, or removed from the facility.
• Shred paper records using an approved secure process when they are no longer needed under the organization’s retention and disposal procedures.

Protect Unattended Workstations and Screens

• Lock or sign out of a workstation before stepping away, even briefly. Set automatic screen locking to activate after an appropriate period of inactivity.
• Close patient records and imaging studies when they are no longer needed. Do not leave visible patient information on a shared or public-facing display.
• Position monitors to reduce viewing by visitors and people without authorization. Use approved privacy screens where the workspace requires them.
• Do not share accounts, passwords, or authentication tokens. Each staff member should use an individual account so activity can be attributed correctly.
• Keep work areas clear of passwords, access badges, printed credentials, and handwritten notes that could expose access details.

Restrict PACS Archive Access

Apply PACS role-based access control so users can access the imaging functions and patient information needed for their assigned duties. Separate administrative privileges from routine clinical access, and avoid shared or overly broad accounts.

• Approve, change, and remove access through a documented process, including when staff change roles or leave the organization.
• Review user permissions regularly, paying particular attention to privileged accounts, temporary access, and third-party support accounts.
• Require strong authentication for access to the archive, including additional verification where risk and system capabilities warrant it.
• Monitor access to studies and archive functions for unusual activity, such as unexpected access patterns, repeated failed logins, or atypical bulk exports.
• Use audit log monitoring to identify and follow up on suspicious activity. Document the review process and the disposition of significant findings.

Encrypt Imaging Data at Rest and in Transit

Establish safeguards for imaging data across the archive lifecycle, including storage, backups, workstations, removable media, and transfers between authorized organizations. DICOM image data encryption can help protect image files and associated patient information against unauthorized disclosure.

• Use organization-approved encryption for data at rest on archive storage, portable devices, and backup media when supported by the system and risk assessment.
• Protect data in transit with secure, approved communication channels when exchanging images or sending them to another facility or service provider.
• Manage encryption keys separately from the data they protect, restrict key access, and maintain procedures for key recovery and rotation.
• Verify that approved transfer methods are used instead of personal email, consumer file-sharing accounts, or unapproved removable media.
• Test that authorized users can retrieve encrypted images and backups when needed for clinical operations and recovery.

Inventory and Secure Imaging Systems

Maintain an up-to-date inventory of PACS components and other systems that store, access, or transmit imaging information. Include relevant servers, workstations, modalities, gateways, storage devices, and backup systems, along with their locations, owners, and support status.

• Document where imaging systems are located and which systems can connect to the archive or access patient information.
• Restrict physical access to archive equipment, network cabinets, and storage areas to authorized personnel. Escort and document visitors where appropriate.
• Apply imaging device vulnerability management procedures to identify, assess, and address security issues in PACS components, modalities, and connected devices.
• Coordinate updates and maintenance with clinical and technical teams so changes are tested, authorized, and documented without compromising patient care.
• Review service-provider access and responsibilities, and ensure arrangements for handling imaging information are documented and approved.

Clear Electronic Media Before Reuse or Disposal

Before reusing, transferring, returning, or disposing of electronic media, follow the organization’s electronic protected health information media sanitization process. Choose an approved method appropriate to the media, its condition, and the sensitivity of the information; simply deleting files may not remove recoverable data.

• Identify media that may contain image files, patient identifiers, cached studies, temporary exports, or archive backups.
• Use a documented, approved sanitization method before reuse or release from the organization’s control. If the media cannot be reliably sanitized, arrange for secure destruction.
• Keep records of the asset, sanitization or destruction method, responsible personnel, date, and verification or disposal documentation.
• Include storage devices in imaging equipment and devices sent for repair, return, or replacement in the review process.
• Apply the organization’s digital image retention schedule and approved records-management procedures before deleting or disposing of imaging data.

Train Staff and Prepare for Security Incidents

Train clinical, technical, and administrative staff on clean desk responsibilities that match their access to the imaging archive. Reinforce the policy during onboarding and refreshers, and make it clear how to report suspected exposure, lost media, unauthorized access, or unusual system behavior.

• Explain how to secure documents, removable media, shared workstations, and visible imaging displays.
• Show staff how to lock a workstation, use approved image-transfer processes, and report lost devices or misdirected imaging data.
• Review relevant audit logs and security alerts regularly, including records of access, failed authentication, exports, configuration changes, and administrator actions where available.
• Maintain a response process that identifies who to contact, how to preserve relevant evidence, and how to limit further exposure while following organizational procedures.
• Reassess the checklist after system changes, incidents, or reviews so that staff practices and technical controls remain aligned.

A reliable clean desk policy combines secure handling of paper and media with controlled PACS access, protected workstations, and documented system and disposal practices. Assign clear responsibilities, train staff, and review the checklist regularly to keep imaging information protected throughout its lifecycle.

FAQs

What should a clean desk policy cover in an enterprise imaging archive?

It should cover the secure handling and storage of printed records and removable media, workstation and screen security, PACS access permissions, image transfers, system inventory, media sanitization, staff training, and reporting suspected incidents. It should also identify who is responsible for each procedure and how completion or review is documented.

How should staff secure unattended PACS workstations?

Staff should lock or sign out of the workstation before leaving it, even briefly, and should close patient records and studies when they are no longer in use. Automatic screen locking, careful monitor placement, individual user accounts, and avoiding visible passwords or credentials add further safeguards.

How should electronic media containing imaging data be cleared before reuse or disposal?

Use an organization-approved sanitization method appropriate to the media and its intended reuse or disposal. If reliable sanitization is not possible, arrange secure destruction. Document the media, method, date, responsible personnel, and any verification or disposal record; follow the organization’s retention procedures before removing imaging data.

What security logs should an imaging archive company review?

Review available records of user access to studies and archive functions, failed login attempts, account and permission changes, exports or other bulk data activity, administrator actions, and relevant security alerts. Establish a regular review process, investigate unusual activity, and document significant findings and follow-up.