EvidenceSheet
HIPAA Security Rule · Policies and Procedures

164.316(b)(2)(ii) Availability (Documentation)

Make documentation available to those persons responsible for implementing the procedures to which the documentation pertains.

8
artefacts
1
held by a system
1
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

  • Availability metrics (page views, downloads, access requests) · Policy repository / GRC workspace

periodic reviewEvidence produced at each review

  • Communication evidence (intranet posts, training references) · HR system / LMS

governing documentDocuments that govern the control

  • Documentation portal or repository accessible to relevant workforce · Policy repository / GRC workspace
  • Access records demonstrating workforce can retrieve relevant policies · Policy repository / GRC workspace
  • Role-based mapping of documentation to responsibility · Policy repository / GRC workspace
  • Workforce acknowledgement of access · HR system / LMS
  • Procedure for distributing updates · Policy repository / GRC workspace
  • Procedures for offline or remote workforce access · Policy repository / GRC workspace

First move

Mostly documents and reviews. Pull the 1 system-held artefact from your Policy repository / GRC workspace on a schedule; put the documents under version control with an owner and review date, and log each review as a dated record with a named reviewer.

Common gaps auditors find

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.

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164.316(b)(2)(i) Time Limit (Documentation Retention) · 164.316(b)(2)(iii) Updates (Documentation)