164.316(a) Policies and Procedures (Standard)
Implement reasonable and appropriate policies and procedures to comply with the Security Rule standards. NIST recommends a managed policy hierarchy with ownership, version control, and review cadence.
Source: HIPAA Security Rule, 164.316(a). 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
- Version history · Policy repository / GRC workspace
periodic reviewEvidence produced at each review
- Annual policy review evidence · Policy repository / GRC workspace
governing documentDocuments that govern the control
- Policy hierarchy map · Policy repository / GRC workspace
- Policy ownership register · Policy repository / GRC workspace
First move
Common gaps auditors find
- Orphan policies without owners
- Policies untouched for years
- Local procedures conflict with corporate policy
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 sheet164.314(b)(2) Implementation Specifications for Group Health Plans · 164.316(b)(1) Documentation (Standard)