HIPAA Security Risk Assessment Example: Sample Report, Controls Mapping, and Remediation Plan

This HIPAA Security Risk Assessment example walks you through a practical sample report, how to map controls to the Security Rule, and how to build a remediation plan that protects Electronic Protected Health Information (ePHI) and stands up to a compliance audit.

Sample Security Risk Assessment Report

Purpose and Scope

The assessment identifies threats and vulnerabilities that could compromise ePHI across your environment. Scope typically includes EHR platforms, patient portals, cloud services, on‑prem systems, medical devices, network infrastructure, and vendors that create, receive, maintain, or transmit ePHI.

Methodology

You gather evidence through interviews, document reviews, configuration sampling, and targeted technical testing. Activities include asset and data‑flow discovery, control evaluation across Administrative Safeguards, Physical Safeguards, Technical Safeguards, and Organizational Safeguards, and validation of operational practices.

Risk Rating Model

Use a simple 1–5 scale for Likelihood and Impact; compute Inherent Risk as L × I and rate High (15–25), Medium (8–14), or Low (1–7). Define what moves scores up or down, then recalculate Residual Risk after proposed controls are implemented.

Sample Findings

• Unencrypted laptops used offsite (High)
  Affected safeguards: Physical, Technical, Administrative. Evidence shows field staff storing ePHI locally without full-disk encryption or MDM. Recommended actions: mandate encryption, enable remote wipe, enforce strong authentication, and update workforce security awareness training.
• MFA absent for VPN and EHR (High)
  Affected safeguards: Technical. Remote access relies only on passwords. Actions: deploy MFA for all remote and privileged access, review access logs, and update access authorization procedures.
• Vendor BAA gaps (Medium)
  Affected safeguards: Organizational. Two data processing vendors lack current BAAs. Actions: execute BAAs, assess vendor controls, and document service responsibilities and breach notification terms.
• Incomplete security awareness training (Medium)
  Affected safeguards: Administrative. Training completion at 76% with phishing click‑through at 11%. Actions: require annual training, targeted refreshers, and simulated phishing until click‑through falls below threshold.

Deliverables

• Executive summary with overall risk posture and top risks.
• Risk Register and Risk Analysis Worksheet for each risk.
• Controls Mapping Matrix aligned to HIPAA Security Rule safeguards.
• Time‑bound Remediation Plan with owners and milestones.
• Appendices: evidence snapshots, diagrams, and policy references for audit readiness.

Mapping Controls to HIPAA Security Rule

Build a Controls Mapping Matrix

Create a two‑way matrix that lists your controls and maps them to HIPAA’s safeguard families. This clarifies coverage, reveals gaps, and produces audit‑ready traceability from requirements to implemented measures and evidence.

Example Mappings

• Access management and MFA → Technical Safeguards (access control, authentication). Evidence: MFA policy, identity system settings, access reviews.
• Security awareness and sanctions → Administrative Safeguards (workforce security, training). Evidence: LMS reports, training materials, sanction records.
• Facility entry controls and device protection → Physical Safeguards (facility access, workstation security). Evidence: badge logs, camera retention, device lock settings.
• Business Associate Agreements and vendor due diligence → Organizational Safeguards. Evidence: executed BAAs, vendor questionnaires, risk rankings.
• Encryption of data at rest and in transit → Technical Safeguards. Evidence: encryption standards, key management documentation, configuration exports.

Traceability Tips

Assign each control a unique ID and list linked policies, procedures, and system configurations. Record testing steps and results so you can demonstrate effective operation during a compliance audit.

Using Risk Assessment Templates

Core Templates You Can Reuse

• Risk Analysis Worksheet: risk statement, assets, ePHI involved, threats, vulnerabilities, existing controls, L/I scores, and proposed treatments.
• Risk Register: portfolio view of all risks with owners, due dates, and status.
• Controls Mapping Matrix: cross‑walk of controls to safeguard families and evidence locations.
• Interview Guide: role‑specific questions for IT, clinical ops, compliance, and vendors.
• Asset and Data‑Flow Inventories: where ePHI is created, stored, transmitted, and disposed.

Tailor Without Overcomplicating

Keep templates lightweight, add fields only when needed, and standardize scoring. Include references to related policies and to any concurrent privacy assessment so security and privacy risks align.

Common Pitfalls

• Templates with vague risk statements that don’t name assets or ePHI flows.
• Scores without criteria, making decisions hard to defend.
• Controls recorded but lacking evidence paths, hindering audits.

Developing a Remediation Plan

Prioritize by Risk and Feasibility

Address High risks first, especially where ePHI exposure could be significant. Identify quick wins (policy updates, configuration toggles) while planning multi‑phase technical work for complex items.

Assign Owners, Budgets, and Dates

Each task needs a single accountable owner, resources, and due dates. Add milestones and dependencies (for example, identity cleanup before MFA) and capture acceptance criteria for verification.

Measure Risk Reduction

For every action, estimate residual Likelihood and Impact. Close the item only after evidence is reviewed and residual risk meets your tolerance; otherwise document a time‑bound risk acceptance.

Example 30/60/90‑Day Plan

• 0–30 days: enable full‑disk encryption, execute missing BAAs, disable legacy remote access, update incident response contacts.
• 31–60 days: deploy MFA for VPN/EHR, tighten logging and alerting, complete workforce training, conduct targeted phishing tests.
• 61–90 days: segment clinical networks, implement backup immutability, complete access recertifications, test disaster recovery.

Conducting Security Risk Assessment Process

Step‑by‑Step Workflow

1. Plan: define objectives, scope ePHI, stakeholders, and timeline.
2. Discover: inventory assets and data flows; review policies, procedures, and contracts.
3. Assess: evaluate controls across Administrative, Physical, Technical, and Organizational Safeguards.
4. Analyze: identify threats and vulnerabilities, score risks using your criteria.
5. Treat: select mitigation, transfer, avoidance, or acceptance strategies.
6. Validate: test fixes, verify evidence, and update residual risk.
7. Report: deliver the report, risk register, and remediation plan to leadership.
8. Maintain: track progress, monitor changes, and prepare for the next cycle and any compliance audit.

Employing Risk Assessment Tools

Tool Categories to Consider

• Questionnaire‑based SRA tools for structured interviews and scoring.
• Asset discovery, data mapping, and MDM to find ePHI and secure endpoints.
• Vulnerability scanners and configuration assessment to uncover technical gaps.
• Identity and access management, MFA, and privileged access monitoring.
• SIEM and log analytics for detection and evidence collection.
• GRC platforms to manage the risk register, workflows, and audit trails.

Selection Tips

Choose tools that export evidence clearly, integrate with your ticketing system, and support your scoring model. Ensure they help you prove control operation, not just find issues.

Documenting Risk Analysis

What to Capture

• Risk statement tied to specific assets and ePHI flows.
• Threats, vulnerabilities, existing controls, and evidence locations.
• Likelihood/Impact, Inherent and Residual Risk, and treatment choice.
• Owner, due date, status, and verification notes.

Records and Retention

Version control all documents, record approvals, and retain evidence according to policy. Keep a clean audit trail that links risks to policies, procedures, and implemented changes.

Link Security and Privacy

Cross‑reference your security risk analysis with the organization’s privacy assessment. This alignment ensures consistent handling of patient rights, minimum necessary use, and disclosures alongside security controls.

Conclusion

By structuring your work products, mapping controls to the HIPAA Security Rule, and executing a prioritized remediation plan, you create a defensible HIPAA Security Risk Assessment example that protects ePHI and streamlines your next compliance audit.

FAQs.

What is included in a HIPAA security risk assessment?

An assessment includes scoping of ePHI, asset and data‑flow inventories, control evaluations across all safeguard families, risk scoring, a Risk Analysis Worksheet for each risk, a consolidated risk register, and a remediation plan with evidence for verification.

How do you map cybersecurity controls to HIPAA requirements?

You build a matrix that ties each control to Administrative, Physical, Technical, and Organizational Safeguards. For every mapping, record the control objective, configuration or process owner, and the evidence you will present during an audit.

What steps are involved in developing a remediation plan?

Prioritize by risk, define actions and milestones, assign owners and budgets, implement controls, and verify effectiveness. Recalculate residual risk and document any time‑bound risk acceptances with leadership approval.

How often should a HIPAA risk assessment be updated?

Update at least annually and whenever significant changes occur, such as new systems handling ePHI, mergers, major vendor changes, or notable security incidents. Continuous monitoring feeds interim updates between formal cycles.