164.312(a)(2)(ii) Emergency Access Procedure (Required)
Establish procedures for obtaining necessary ePHI during an emergency. NIST recommends break-glass accounts, time-bounded activation, and full logging.
4
artefacts
0
held by a system
3
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
- Vaulted credential evidence · Identity provider / directory
- Activation log review records · SIEM / log platform
- Post-use rotation evidence · Document repository
governing documentDocuments that govern the control
- Break-glass procedure · 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
- Break-glass not tested
- Activation not logged
- Credentials not rotated after use
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 sheet164.312(a)(2)(i) Unique User Identification (Required) · 164.312(a)(2)(iii) Automatic Logoff (Addressable)