Security Risk Assessment Checklist for HIPAA Compliance: What to Include

A focused security risk assessment is the foundation of HIPAA Security Rule compliance. Use this Security Risk Assessment Checklist for HIPAA Compliance: What to Include to identify threats to electronic protected health information (ePHI), prioritize remediation, and document the safeguards regulators expect to see.

Risk Analysis Processes

Your analysis defines scope, methods, and evidence. Capture every system, workflow, location, and third party that creates, receives, maintains, or transmits ePHI, then evaluate risk to confidentiality, integrity, and availability.

Checklist

• Define scope: environments, applications, devices, data stores, and vendors handling ePHI.
• Map ePHI data flows from creation to disposal, including telehealth and remote work paths.
• Inventory assets and classify data to reflect sensitivity and business criticality.
• Identify threats and vulnerabilities using structured vulnerability assessment techniques.
• Score likelihood and impact with a consistent methodology; rank risks in a register.
• Validate findings with system owners and clinical leaders to confirm real-world context.
• Document methodology, assumptions, and evidence to support compliance audit procedures.

Evidence to Maintain

• Current scope statement, data-flow diagrams, asset lists, and business process maps.
• Risk register with ratings, owners, due dates, and status.
• Scanning reports, penetration test summaries, and remediation tickets.

Risk Management Strategies

Translate analysis into action. Decide how you will treat each risk, assign ownership, and verify outcomes so residual risk is known and accepted at the right level.

Checklist

• Create a risk treatment plan: mitigate, transfer, avoid, or accept each item.
• Define specific controls, budgets, owners, and deadlines tied to business priorities.
• Integrate remediation into change management to ensure traceability and testing.
• Track metrics (closure rates, time-to-remediate, residual risk trends) and report to leadership.
• Formalize risk acceptance with executive sign-off and review dates.
• Extend management to vendors with due diligence, BAAs, and service-level expectations.

Administrative Safeguards Implementation

Administrative safeguards convert policy into daily practice. They set expectations, define access, and institutionalize oversight across your workforce and partners.

Checklist

• Publish and enforce access control policies aligned to the minimum necessary standard.
• Establish workforce security processes: hiring, onboarding, termination, and sanctions.
• Run ongoing risk management and document decisions, approvals, and exceptions.
• Implement compliance audit procedures: internal reviews, monitoring, and corrective actions.
• Maintain contingency plans for backup, disaster recovery, and emergency operations; test them.
• Assign security responsibility, define roles, and conduct periodic policy reviews.
• Execute and manage Business Associate Agreements (BAAs) with appropriate oversight.

Physical Safeguards Measures

Physical safeguards restrict and monitor real-world access to facilities and devices, protecting ePHI from theft, tampering, and accidental exposure.

Checklist

• Control facility access with badges, keys, visitor logs, and escort policies.
• Harden workstations: secure placement, privacy screens, automatic logoff, and cable locks.
• Manage device and media controls: inventory, chain-of-custody, secure reuse, and certified disposal.
• Protect equipment with environmental safeguards (UPS, temperature, leak detection) and maintenance logs.
• Secure storage and transport of portable media and backups with documented custody.

Technical Safeguards Deployment

Technical safeguards implement access, monitoring, and protection controls that enforce policy and reduce exploitable attack surface across your systems.

Checklist

• Apply role-based access with unique IDs and multifactor authentication enforcing access control policies.
• Enable audit controls: centralized logging, time sync, tamper-resistant storage, and defined retention.
• Protect integrity with allow-listing, file integrity monitoring, and verified updates.
• Use data encryption standards for ePHI at rest and in transit with strong key management.
• Secure transmission channels with current protocols, VPNs where appropriate, and certificate management.
• Harden configurations, patch routinely, and segment networks to isolate critical systems.
• Back up ePHI regularly with encrypted, recoverable, and periodically tested backups.

Security Training Programs

Training turns policy into behavior. Build role-based curricula that emphasize reporting, safe handling, and clear consequences for violations.

Checklist

• Deliver onboarding and annual training tailored to clinical, billing, IT, and leadership roles.
• Teach phishing defense, secure passwords, device handling, remote work, and data labeling.
• Define and communicate security violation protocols, including reporting and sanctions.
• Run simulations and drills; track completion, comprehension, and incident reporting rates.
• Provide quick-reference job aids and update content when systems or risks change.

Incident Response Planning

A documented, practiced plan for security incident response reduces impact and supports timely notifications and recovery when events occur.

Checklist

• Establish an incident response team with clear roles, contact rosters, and decision authority.
• Create playbooks for common scenarios: ransomware, lost or stolen device, misdirected email, or improper access.
• Define detection, triage, containment, eradication, and recovery procedures with evidence handling.
• Integrate legal, privacy, HR, and communications for investigation and stakeholder updates.
• Assess breach probability, document analysis, and execute applicable notification steps.
• Conduct post-incident reviews, track corrective actions, and update plans and controls.
• Exercise the plan with tabletop tests and measure time-to-detect, contain, and recover.

Conclusion

Use this checklist to analyze risk, manage remediation, and implement administrative, physical, and technical safeguards that protect ePHI. Reinforce behavior with training, and prepare with mature incident response so you can demonstrate HIPAA compliance and resilient operations.

FAQs

What is the purpose of a security risk assessment under HIPAA?

Its purpose is to systematically identify and evaluate risks to the confidentiality, integrity, and availability of ePHI, determine appropriate safeguards, and document due diligence required by the HIPAA Security Rule to guide ongoing risk management.

How often should a security risk assessment be conducted?

You should perform an assessment at least annually and whenever significant changes occur—such as new systems, major process updates, mergers, or notable threats—or after an incident, ensuring the analysis remains current and actionable.

What are the key components of HIPAA compliance in risk assessments?

Key components include scoping ePHI and data flows, identifying threats and vulnerabilities, rating likelihood and impact, documenting results, implementing risk management and safeguards (administrative, physical, and technical), conducting security training, planning incident response, and maintaining evidence for compliance audit procedures.

How do physical safeguards protect ePHI?

Physical safeguards limit and monitor facility and device access, prevent viewing or theft of information, protect equipment from environmental hazards, and ensure secure movement, reuse, and disposal of hardware and media that may store ePHI.