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.
4
artefacts
1
held by a system
0
at each review
moderate
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
- Version history · Policy repository / GRC workspace
periodic reviewEvidence produced at each review
none for this control
governing documentDocuments that govern the control
- Policy hierarchy map · Policy repository / GRC workspace
- Policy ownership register · Policy repository / GRC workspace
- Annual policy review evidence · Policy repository / GRC workspace
First move
Start with the 1 of 4 artefacts that already live in a system (Policy repository / GRC workspace); keep the periodic reviews but log each one as a dated record with a named reviewer.
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)