164.316(b)(2)(iii) Updates (Documentation)
Review documentation periodically, and update as needed, in response to environmental or operational changes affecting the security of ePHI.
8
artefacts
0
held by a system
3
at each review
hard
to go live
Document repository
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
- Documentation review schedule (annual minimum) · Document repository
- Review records with reviewer name, date, and outcome · Document repository
- Trigger inventory (events that mandate review) · Policy repository / GRC workspace
governing documentDocuments that govern the control
- Update history triggered by environmental or operational changes (M&A, new systems, regulatory updates) · Document repository
- Version control demonstrating supersession · Document repository
- Communication of updates to workforce · Policy repository / GRC workspace
- Workforce re-acknowledgement after material updates · HR system / LMS
- Linkage to risk analysis updates · Document repository
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
- Documentation not reviewed annually
- Updates triggered only by audit findings
- Version control absent or inconsistent
- Workforce not informed of changes
- No linkage between risk analysis updates and policy updates
- Change triggers undefined
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 sheet