164.308(a)(1)(i) Security Management Process (Standard)
Implement policies and procedures to prevent, detect, contain, and correct security violations. NIST recommends establishing an enterprise security governance program with defined roles and risk-based decision making.
Source: HIPAA Security Rule, 164.308(a)(1)(i). The statement above is our statement of the clause, read from the published text and cited so you can check it against the official text, not the instrument verbatim. Open HIPAA Security Rule in the compliance library.
Applies to covered entities and business associates. An addressable specification can be met by a documented, reasonable alternative.
These are the artefacts auditors commonly ask for on this requirement, our guidance rather than text from the standard. Your assessor decides what is sufficient in your context, and asks for samples across the period when a report covers one.
system holds itEvidence a system already holds
none for this control
periodic reviewEvidence produced at each review
- Governance committee minutes · Policy repository / GRC workspace
governing documentDocuments that govern the control
- Information security policy · Policy repository / GRC workspace
- Security program charter · Policy repository / GRC workspace
- Risk management framework documentation · Document repository
First move
Common gaps auditors find
- No designated governance body
- Policies exist but not approved
- Program lacks executive sponsorship
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 sheet164.306 Security Standards: General Rules · 164.308(a)(1)(ii)(A) Risk Analysis (Required)