164.306 Security Standards: General Rules
Covered entities and business associates must ensure the confidentiality, integrity, and availability of all electronic protected health information (ePHI) they create, receive, maintain, or transmit; protect against rea
8
artefacts
0
held by a system
2
at each review
hard
to go live
Policy repository / GRC workspace
where the evidence lives
teal = a system already holds it · olive = produced at each review
system holds itEvidence a system already holds
none for this control
periodic reviewEvidence produced at each review
- Annual security program review minutes with executive sign-off · Policy repository / GRC workspace
- Workforce compliance attestation records · Vendor register / contract repository
governing documentDocuments that govern the control
- Information security program charter signed by executive leadership · Policy repository / GRC workspace
- Documented determination of covered entity vs. business associate status · Policy repository / GRC workspace
- EPHI inventory and data flow diagrams identifying creation, receipt, maintenance, transmission · Policy repository / GRC workspace
- Documented rationale for flexibility of approach decisions citing size, complexity, capabilities, costs, risk · Policy repository / GRC workspace
- Statement of applicability mapping security measures to CIA triad · Policy repository / GRC workspace
- Risk acceptance register for residual risks · Policy repository / GRC workspace
First move
This control is evidenced by people and documents, not systems. Put the document under version control with an owner and review date, and log each review as a record with reviewer and date. Do not try to automate it.
Common gaps auditors find
- No documented justification for addressable specification decisions
- ePHI inventory incomplete or stale (missing SaaS, mobile, backup repositories)
- Flexibility decisions not tied back to risk analysis
- Workforce attestations expired or not collected for new hires
- No clear demarcation of covered entity vs. business associate functions
- Executive sign-off missing on security program documents
Do this for your whole sheet
Paste the rows you run your controls from and get this mapping for every control at once, with the periodic-review ones flagged and a first move per row. No account for the first run.
Build my evidence sheet