Professional Sports Team Medical Department Security Risk Assessment Checklist

A professional sports team’s medical department handles sensitive information and equipment across clinics, training facilities, stadiums, hotels, and travel settings. Use this checklist to identify risks, document decisions, and prioritize safeguards for people, records, medications, devices, and clinical operations.

HIPAA applies to covered entities and business associates—not automatically to every sports team or medical department. Determine the team’s and its clinicians’ roles and relationships before treating a particular record or system as subject to HIPAA. Where the HIPAA Security Rule applies, it requires an accurate and thorough risk analysis of risks and vulnerabilities to electronic protected health information (ePHI), with reasonable and appropriate safeguards informed by the organization’s circumstances. See HHS guidance on HIPAA Security Rule risk analysis.

How should medical department assets and sensitive data be inventoried?

Start with a complete inventory of the information, systems, people, and physical assets used to deliver care. Include assets owned by the team and those operated by clinicians, hospitals, laboratories, cloud providers, or other partners.

• List medical records and data flows, including electronic health records (EHRs), injury and treatment notes, imaging, prescriptions, rehabilitation plans, lab results, appointment schedules, billing records, and paper files.
• Identify data stored or shared through team-issued phones and computers, personal devices approved for work, email, messaging, video visits, shared drives, cloud services, removable media, and backups.
• Inventory connected and standalone clinical equipment, such as diagnostic systems, monitoring equipment, rehabilitation technology, and devices that store or transmit health information.
• Record where each asset is located, who owns and administers it, who can access it, how it connects to other systems, and what happens to the data when the asset is replaced or retired.
• Classify information by sensitivity and purpose. Track where identifiable health information is collected, viewed, stored, transmitted, printed, or disposed of.
• Map the movement of records between the team, players, clinicians, outside providers, insurers, laboratories, and service vendors. Identify paper handoffs and informal channels as well as electronic exchanges.

Protected health information (PHI) generally includes individually identifiable health information held or transmitted by a covered entity or its business associate, in electronic, paper, or oral form. Records maintained by an employer in its capacity as an employer are treated differently under HIPAA, so assess the context and responsible entity rather than assuming every health-related team record has the same status. See HHS’s Summary of the HIPAA Privacy Rule.

Document the inventory’s scope, assumptions, identified risks, existing safeguards, and corrective actions. HHS notes that risk analysis can include an inventory of systems and applications that access or house ePHI, and that there is no single assessment method or fixed federal schedule for every organization. See HHS guidance on risk analysis and risk management.

How can access to medical records and treatment areas be controlled?

Limit access to the people who need it for their assigned responsibilities, and review those permissions whenever roles or work arrangements change. Role-based access control can help translate clinical and operational duties into specific permissions.

• Assign unique user accounts; avoid shared logins for clinical systems and document any narrowly scoped emergency access process.
• Give clinicians, athletic trainers, administrators, coaches, players, and contractors only the access needed for their duties. Separate clinical access from performance, scouting, and general team operations where appropriate.
• Use multi-factor authentication (MFA) for remote access and other accounts where the risk warrants it. Treat MFA as a strong security practice, not as a safeguard expressly named in every HIPAA requirement.
• Review access regularly and promptly disable accounts when staff, contractors, or vendors leave or no longer need access.
• Set automatic screen locks, protect devices from casual viewing, and provide a secure process for remote access and lost-device reporting.
• Restrict treatment-room, records-room, medication-storage, and equipment-room access to authorized personnel. Use visitor sign-in, escorts, keys or badges, and secure storage as appropriate to the location.
• Train workforce members on confidentiality, appropriate record access, secure communications, and how to report a suspected privacy or security incident.

The HIPAA Security Rule requires regulated entities to have policies and procedures for authorizing access to ePHI appropriate to the user’s role, and physical safeguards to limit access to facilities and systems while allowing properly authorized access. See HHS’s Summary of the HIPAA Security Rule.

What cybersecurity controls protect electronic health records and connected devices?

Build controls around the risks identified in the assessment, including unauthorized access, phishing, ransomware, accidental disclosure, device loss, and service outages. Apply safeguards to EHRs and to any other system that creates, receives, maintains, or transmits ePHI.

• Use secure authentication, least-privilege permissions, MFA where appropriate, and a documented process for managing accounts and credentials.
• Review electronic health record audit logs for unusual access, repeated failed logins, access outside expected work patterns, and inappropriate viewing or changes to records. Define who reviews alerts and how concerns are escalated.
• Use endpoint protection and consider endpoint detection and response (EDR) to identify suspicious activity on supported computers and mobile devices. Document monitoring coverage and response responsibilities.
• Keep operating systems, applications, and supported devices updated; prioritize security fixes based on risk and vendor guidance.
• Protect information in transit and at rest where appropriate. HIPAA treats encryption specifications as addressable, which requires an organization to assess whether they are reasonable and appropriate, document its decision, and implement an equivalent measure if encryption is not reasonable and appropriate.
• Maintain secure, tested backups and limit who can alter or delete them. Prepare for recovery if systems are unavailable or data is damaged.
• Separate medical systems and connected devices from less trusted networks where practical, and disable unused accounts, ports, services, and remote access.
• Maintain an approved-software and device list, vulnerability-management process, and secure configuration standards.

Medical device cybersecurity should account for device function, the sensitivity of any data it handles, connectivity, support status, and the potential impact of downtime or compromise on patient care. Coordinate updates and security actions with the manufacturer and clinical engineering so safeguards do not disrupt safe device operation. The FDA’s medical device cybersecurity guidance describes recommendations for cybersecurity in device design and lifecycle management; it is guidance for industry, not a substitute for the team’s own risk analysis.

How should medications, medical supplies, and equipment be secured?

Protect medication and equipment integrity as well as their availability for care. Assign clear responsibility for storage, access, inventory, maintenance, and handoffs at each permanent and temporary clinical location.

• Secure medication storage and restrict access to authorized personnel. Use appropriate temperature, light, and environmental controls for products that require them.
• Maintain inventory and reconciliation procedures for medications and high-value supplies; document receipt, use, transfer, return, expiration, and disposal as appropriate.
• Determine which federal, state, and local requirements apply to the team’s medications and storage practices, and follow the organization’s approved procedures.
• Keep supplies and equipment in locked or supervised areas when not in use. Label assets, record transfers, and avoid leaving them unattended in public or shared spaces.
• Inspect equipment before use, track maintenance and service history, and remove damaged, expired, unsupported, or potentially compromised items from service until reviewed.
• Secure portable devices and accessories during transport, and keep an accountable handoff record when equipment moves between facilities or personnel.
• Dispose of records, devices, and media securely; remove stored information from equipment before it is returned, resold, or discarded.

What risks arise during travel, events, and temporary clinical operations?

Travel and event operations change the physical environment, network connections, staffing, and custody of records and equipment. Assess each trip or temporary clinic before departure, then brief the staff who will use its systems and spaces.

• Identify which medical records, devices, medications, and supplies will travel, who is responsible for them, and how they will be secured in transit and at the destination.
• Use approved, access-controlled systems rather than storing more identifiable information locally than the work requires. Confirm how staff can access necessary records if the primary system is unavailable.
• Protect laptops, tablets, phones, and paper files from loss, theft, and viewing by unauthorized people. Avoid leaving them unattended in vehicles, hotel rooms, locker rooms, or shared spaces.
• Use organization-approved network connections and remote-access protections. Avoid transmitting sensitive information through public or unapproved Wi-Fi, messaging, or file-sharing services.
• Define who can enter temporary treatment areas, where visitors wait, how private conversations are protected, and how records and medication are secured when the area is not staffed.
• Set up a reliable method to contact the security or privacy lead, report lost equipment, and reach clinical leadership during travel and events.
• Plan for local hazards such as power loss, severe weather, venue evacuation, connectivity failure, and delayed access to replacement equipment or supplies.

Include travel and temporary operations in the broader risk analysis whenever they affect ePHI or systems that handle it. HHS advises organizations to account for their particular environment and to update security measures as needed when risks, technology, or operations change. See HHS guidance on ongoing risk analysis.

How should vendors, contractors, and third-party systems be assessed?

Identify every outside party that may access, store, transmit, support, or affect medical information or clinical systems. Assess the vendor’s actual role and the data involved before deciding what contracts and safeguards are required.

• Document the service, data exchanged, access granted, hosting location, subcontractors, support model, and connection to team systems.
• Determine whether a vendor is acting as a HIPAA business associate. If HIPAA requires it, put a business associate agreement in place before allowing the vendor to handle PHI on the covered entity’s behalf.
• Review the vendor’s access controls, MFA options, encryption, audit logging, incident reporting, backup and recovery practices, vulnerability management, and support lifecycle.
• Clarify who investigates suspicious activity, how quickly the vendor must notify the team, what information an incident report must contain, and how evidence will be preserved.
• Define approved uses and disclosures, retention and secure deletion requirements, return of data at contract end, and the process for removing vendor accounts and connections.
• Assess integrations with EHRs, wearable technology, performance platforms, telehealth services, laboratories, imaging providers, and cloud storage for unnecessary data sharing or excessive permissions.
• Reassess vendors when services, data flows, ownership, subcontractors, or security conditions change, and at intervals consistent with the organization’s risk-management process.

When a vendor qualifies as a business associate, HIPAA requires appropriate written assurances and safeguards for PHI handled on the covered entity’s behalf. Do not assume that every supplier or contractor is a business associate simply because it works with the team; assess the relationship and service. See HHS’s explanation of business associate responsibilities.

How can incident response and continuity plans be tested?

Make sure staff know how to report suspected loss, unauthorized access, phishing, malware, device theft, or disruption to clinical systems. A report should reach the designated privacy, security, or clinical lead promptly, even if the facts are incomplete.

• Maintain written steps for triage, escalation, containment, investigation, recovery, and documentation. Provide a reporting route that staff can use during travel, events, and after hours.
• Identify who can isolate a device or account, contact vendors, preserve logs and evidence, assess clinical impact, and approve a return to normal operations.
• Prepare for system outages with tested procedures for restoring data and continuing essential operations while protecting ePHI.
• Practice scenarios such as a stolen laptop, compromised account, ransomware, unavailable EHR, lost medication shipment, or vendor outage. Include the medical, IT, privacy, legal, communications, and operations roles needed to respond.
• Record what the exercise or incident revealed, assign corrective actions and owners, and verify that fixes are completed.
• Review whether an event may require notification under applicable law or contract. Do not assume every security incident is automatically a reportable HIPAA breach; the responsible entity must assess the facts and follow applicable requirements.
• Retain required assessment and incident documentation in line with applicable HIPAA recordkeeping rules and organizational policy.

The HIPAA Security Rule requires regulated entities to address and document security incidents and to establish contingency procedures for emergencies affecting systems with ePHI. HHS also describes requirements for backup, restoration, and continued operations during emergencies. See HHS’s Summary of the HIPAA Security Rule and HHS guidance on ransomware response.

A practical assessment should result in a documented inventory, prioritized risks, assigned corrective actions, and tested safeguards for records, people, equipment, travel, vendors, and continuity. Revisit the assessment when operations or technology change and use lessons from exercises and incidents to strengthen protections.

FAQs.

How often should a sports team medical department conduct a security risk assessment?

HIPAA does not set one fixed frequency for every organization’s risk analysis. If the Security Rule applies, the organization should keep its analysis current and update security measures as needed, including when systems, vendors, locations, or operations change or new risks emerge. An annual review may be a useful organizational practice, but it is not a universal federal annual requirement. See HHS guidance on risk analysis frequency and updates.

Which medical department records are considered protected health information?

When held or transmitted by a HIPAA covered entity or its business associate, identifiable information about an individual’s health, care, or payment for care can be PHI. Examples may include treatment notes, injury evaluations, prescriptions, imaging, lab results, and identifiable rehabilitation records. HIPAA status depends on the entity and context: health-related information an employer maintains in its capacity as an employer is treated differently. See HHS’s explanation of protected health information.

How should staff report suspected loss or unauthorized access to medical data?

Staff should promptly use the team’s designated incident-reporting channel and notify the appropriate privacy, security, or clinical lead. They should share what happened, when it was discovered, which device, system, or records may be involved, and any steps already taken. They should not delete messages, wipe devices, or investigate beyond their role unless instructed. The response team can then contain the issue, preserve evidence, assess impact, and determine whether further action or notification is required.

What security controls should be reviewed before team travel?

Confirm that travel devices and accounts are authorized, protected by appropriate authentication, and configured for secure remote access; that staff know how to report a lost device or suspected incident; and that only necessary records and supplies will travel. Review equipment and medication custody, access to temporary treatment spaces, approved network and communications methods, emergency contacts, and a plan for EHR or connectivity outages. Reassess these controls when the itinerary, venue, or clinical setup changes.