HIPAA Security Risk Assessment Example: Step-by-Step Guide with Templates

Setting Assessment Scope

This HIPAA security risk assessment example shows you how to scope, analyze, and document risk to Electronic Protected Health Information (ePHI) with clear, repeatable steps. Your goal is to support HIPAA Security Rule Compliance while creating evidence that stands up to audits.

Define purpose and boundaries

Specify why you are assessing risk (e.g., annual review, new EHR rollout) and what is in or out of scope. Include business units, facilities, networks, cloud tenants, and third parties that create, receive, maintain, or transmit ePHI.

Scope template

• Objective: [Why are you performing this assessment?]
• Organizational boundary: [Entities, departments, locations]
• Systems and assets: [EHR, billing, portals, mobile, backups, cloud]
• Data types: [ePHI categories, volumes, sensitivity]
• Processes and data flows: [Intake → storage → transmission → disposal]
• Third parties/BAAs: [Vendors handling ePHI, integration scope]
• Assumptions/exclusions: [What is excluded and why]
• Timeframe: [Assessment start/end dates, review cadence]

Roles and responsibilities

• Executive sponsor (A): Accountable for outcomes and risk decisions.
• Security lead (R): Runs the assessment and coordinates evidence.
• System owners (R/C): Supply asset details and remediation plans.
• Compliance/Privacy (C): Aligns with HIPAA Security Rule Compliance.
• IT operations (R): Provides configurations, logs, and architecture.
• Internal audit (I): Independently reviews method and results.

Collecting Data from ePHI Sources

Begin with an authoritative inventory of ePHI repositories and flows. Map where ePHI is created, received, maintained, and transmitted so you can test controls where risk actually resides.

Common ePHI sources to include

• EHR/EMR platforms, patient portals, telehealth tools
• Billing/RCM, claim clearinghouses, scheduling systems
• Email and secure messaging used for ePHI
• Endpoints: laptops, tablets, smartphones, scanners
• Servers, databases, file shares, virtualization hosts
• Cloud services: IaaS, PaaS, SaaS, backups, object storage
• Medical devices and IoT that store or transmit ePHI
• Removable media and offsite archives

Asset and data flow inventory template

• Asset ID and owner: [Name/role]
• System description: [Function and ePHI role]
• Data classification: [Type of ePHI, sensitivity]
• Connectivity: [Interfaces, protocols, external connections]
• Locations: [On‑prem, cloud region, facility]
• Data flows: [Source → process → destination]
• Control references: [Policies, procedures, technical safeguards]

Evidence collection methods

• Document review: policies, network diagrams, BAAs, SOPs
• Interviews and walkthroughs with system and process owners
• Technical discovery: configuration exports, vulnerability scans
• Log sampling and audit trail reviews for access and anomalies
• Observation: physical safeguards, workstation use, media handling

Evidence tracker template

• Evidence ID and source: [System/owner/date]
• Description and scope: [What the evidence proves]
• Control mapped: [HIPAA safeguard and control ID]
• Status: [Requested/received/validated]
• Retention: [Repository and retention period]

Documenting Risks and Vulnerabilities

Use consistent language for Vulnerability Identification. A threat is a potential cause of an unwanted incident; a vulnerability is a weakness that can be exploited; a risk is the possibility that a threat exploits a vulnerability to impact ePHI confidentiality, integrity, or availability.

Risk statement template

There is a risk that [threat] exploits [vulnerability] in [asset/process], resulting in [impact on ePHI and operations].

Vulnerability identification checklist

• Access control gaps: excessive privileges, shared accounts
• Authentication issues: weak MFA coverage, default credentials
• Encryption gaps: data at rest or in transit not protected
• Logging/audit gaps: missing audit trails for ePHI access
• Patching/configuration drift: unsupported OS, misconfigurations
• Contingency planning gaps: RTO/RPO misaligned with criticality
• Physical security issues: unrestricted areas, device/media control
• Third‑party risks: incomplete BAAs, unclear breach responsibilities

Risk register template

• Risk ID and title: [Concise name]
• Asset/process affected: [Where the risk lives]
• Threat and vulnerability: [Pairing used in risk statement]
• Existing controls: [Administrative, physical, technical]
• Likelihood and impact: [Qualitative or quantitative]
• Risk rating: [Low/Medium/High/Critical]
• Owner and due date: [Accountable role and timeline]
• Treatment: [Mitigate, accept, transfer, avoid]
• Residual risk: [Post‑treatment rating]

Evaluating Existing Security Protocols

Perform a Security Control Evaluation to measure design and operating effectiveness of safeguards mapped to the HIPAA Security Rule. Consider administrative, physical, and technical controls together, not in isolation.

Control categories and examples

• Administrative: risk management policy, workforce training, sanction policy, contingency planning, vendor oversight
• Physical: facility access controls, workstation security, device and media controls
• Technical: access control, unique IDs, MFA, encryption, audit controls, integrity mechanisms, transmission security

Control evaluation template

• Control ID and description: [What the control does]
• Requirement mapping: [HIPAA safeguard reference]
• Design effectiveness: [Adequate/Partial/Gapped + rationale]
• Operating effectiveness: [Effective/Needs improvement + evidence]
• Compensating controls: [If primary is not fully effective]
• Gap severity and remediation recommendation: [Action and priority]

Gap analysis tips

• Trace every control to an ePHI data flow to confirm coverage.
• Validate automation scope (e.g., MFA coverage rates, encryption status).
• Test one control across multiple systems to uncover inconsistency.

Calculating Risk Probability and Impact

Apply a consistent Risk Probability Assessment so ratings are comparable across assets. If you lack metrics, start qualitatively, then calibrate with incident, audit, and scan data.

Scoring template (qualitative)

• Likelihood: Rare (1), Unlikely (2), Possible (3), Likely (4), Almost certain (5)
• Impact on ePHI: Minor (1), Limited (2), Moderate (3), Major (4), Severe (5)
• Risk score: Likelihood × Impact = 1–25
• Rating bands: 1–4 Low, 5–9 Moderate, 10–16 High, 17–25 Critical

Impact dimensions

• Confidentiality: unauthorized disclosure of ePHI
• Integrity: improper alteration of clinical documentation
• Availability: downtime affecting patient care or operations
• Regulatory/financial: breach notification, penalties, response costs
• Reputation and patient trust: loss of confidence and retention

Example

Unencrypted laptop with ePHI used offsite: Likelihood 4 (Likely) × Impact 4 (Major) = 16 (High). Treatment: enable full‑disk encryption, enforce device management, tighten offsite use policy.

Organizing Risks by Priority

Translate scores into action using a Risk Prioritization Matrix. Group similar issues, assign owners, and stage remediation to reduce the most significant exposure first.

Prioritization matrix template

• Quadrant A (High likelihood/High impact): Immediate remediation and executive oversight
• Quadrant B (Low likelihood/High impact): Compensating controls and monitoring
• Quadrant C (High likelihood/Low impact): Process improvements and automation
• Quadrant D (Low likelihood/Low impact): Accept or schedule for later hardening

Action plan template

• Mitigation task: [What will be done]
• Control owner: [Accountable role or team]
• Milestones: [Start, key checkpoints, completion date]
• Resources: [Budget, tools, vendor assistance]
• Success criteria: [Measurable reduction in risk rating]
• Status and blockers: [Weekly updates]

Operational tips

• Bundle quick wins (policy fixes, config changes) for early risk reduction.
• Schedule complex items (network segmentation, identity redesign) as projects.
• Tie each initiative to a target residual risk and evidence of completion.

Preparing the Final Risk Assessment Report

Package clear, defensible Risk Assessment Documentation that enables decisions and demonstrates HIPAA Security Rule Compliance. Keep the narrative concise and the appendices thorough.

Report outline template

• Executive summary: top risks, heat map, and required decisions
• Scope and methodology: what you assessed and how
• System and data overview: key ePHI flows and dependencies
• Findings: risks with evidence, scores, and affected assets
• Prioritized remediation plan: owners, milestones, resources
• Residual risk and acceptance: rationale for any accepted risks
• Compliance alignment: mapping to HIPAA safeguards and policies
• Appendices: inventory, risk register, control evaluations, evidence list

Sign‑off and follow‑through

• Obtain documented approvals from executive sponsor and system owners.
• Schedule quarterly progress reviews and annual reassessment.
• Update policies, procedures, and training to reflect new controls.

Conclusion

By scoping precisely, inventorying ePHI, documenting risks, evaluating controls, and scoring consistently, you create a repeatable assessment that drives action. The templates above help you prioritize remediation and maintain HIPAA Security Rule Compliance year‑round.

FAQs

What is included in a HIPAA security risk assessment?

A complete assessment includes scope definition, ePHI asset and data flow inventory, Vulnerability Identification, Security Control Evaluation, risk scoring for likelihood and impact, a prioritized remediation plan, and formal Risk Assessment Documentation with sign‑offs and evidence.

How often should a HIPAA risk assessment be conducted?

Perform a comprehensive assessment at least annually and whenever major changes occur, such as deploying new systems, onboarding vendors that handle ePHI, or significant process changes. Review progress quarterly to track mitigation and residual risk.

What templates can help with HIPAA risk assessments?

Use a scope worksheet, asset and data flow inventory, evidence tracker, risk statement and register, control evaluation checklist, Risk Prioritization Matrix, and a final report outline. These templates keep work consistent and audit‑ready.

How do you prioritize risks in a HIPAA assessment?

Score likelihood and impact, plot items on a Risk Prioritization Matrix, and act first on high‑likelihood, high‑impact risks. Assign owners, set milestones, and measure residual risk to confirm that remediation meaningfully reduces exposure to ePHI.