HIPAA Part 3: Document! Document! Document!

hipaa documentation

As you read through the Privacy and Security Rules for HIPAA, you’ll see a pattern that shouldn’t be taken for granted. Nearly all the implementation specifications require some form of policy and procedure documentation. This involves more than the reasoning and justification for how you choose to implement the specifications (though that must be documented as well). These are the policies and procedures that HIPAA expects your business to follow every day.

Organizational Standards

Besides the administrative, physical, and technical safeguards which make up the majority of the Security Rule, there is a lesser known section of safeguards called organizational standards that deal largely with the paperwork required by HIPAA concerning protected health information (PHI) in any form. This section is often overlooked because many of its requirements are addressed in greater detail throughout the Privacy and Security Rules. The four standards in this section include:

  • Business Associate Contracts
  • Requirements for Group Health Plans
  • Policies and Procedures
  • Documentation

This article focuses on the last two standards: Policies and Procedures and Documentation, both of which lay the groundwork for HIPAA compliance. The other two standards shouldn’t be ignored, but they concern only those who: a) are or need a business associate or, b) are a sponsor to a group health plan that provides data beyond enrollment and summary information.

Note: If you work with or are a business associate that works with ePHI and your contract has not been updated since the HITECH Act in 2009 or the Final Omnibus HIPAA Rule in 2013, you will want to review and update all contracts to ensure they meet the current standards regarding business associates.

Standard 164.316(a): Policies and Procedures

Why have an entire standard dedicated to something addressed in nearly every single implementation standard? This standard explains what HIPAA expects from the policies and procedures that a business creates. Specifically, it references the Security Standards’ General Rule of Flexibility of Approach, which is discussed in Part 2 of this series. It also allows for policies and procedures to be changed at any time to adjust to new demands or technologies, as long as all changes are documented and implemented accordingly.

Standard 164.316(b)(1): Documentation

This standard identifies how documentation required by HIPAA is to be maintained. According to this standard and its subsequent implementation standards, all documentation required throughout the Security Rule’s standards, including but not limited to

  • policies and procedures,
  • job responsibilities and duties,
  • risk assessments, and
  • action plans

must be recorded (physically or electronically) and retained for a minimum of six years from the date of creation or when it was last in use, whichever date is later. All documentation must be available to anyone who uses those procedures, and documentation should be consistently reviewed and updated as necessary.

Note: The six-year retention rule only satisfies HIPAA standards. State law may require some documentation to be retained for longer. Always verify what state laws apply to your business, as HIPAA does not supersede many state requirements.

Bringing Your Policies into Compliance

It’s possible your business already has clear policies and procedures in place, but that doesn’t immediately make you HIPAA compliant. You still need to go through each one to ensure it satisfies the implementation specifications it pertains to. If not, policies may need to be updated or new ones added. HIPAA gives businesses a great deal of leeway in how policies and procedures are written, so both updating existing documentation and creating all new materials is acceptable.

What should the policies and procedures say?

HIPAA doesn’t dictate the exact wording of any policy or procedure. It’s up to the business, taking into consideration the Flexibility of Approach guidelines, to determine what policy needs to be implemented. Generally, a policy explains a business’s approach to the subject it relates to.  If the policy concerns removing access from those who no longer work for the company, it could read something like:

At the end of an employee’s last day of employment with [company name], security and/or IT staff will remove that employee’s access to company systems and restricted locations and document the change of access. The employee’s supervisor will verify that all access has been revoked within twenty-four hours.

This offers clear guidance about what the company intends to do to remove access from someone who no longer is allowed to work with PHI. It also provides an implementation timeline, who should implement the policy, and how the company will ensure it gets implemented properly.

The procedure that accompanies the policy would then offer easy-to-follow directions on how those responsible are to implement the policy. A sample procedure may look like this:

Regarding Policy for Removing Access of Former Employees

Duty of IT Staff or Managed Services Provider

  1. Go to [directory] and locate the list of all programs and devices employee had access to according to job title. Check this list against their user account to ensure no programs are missed.
  2. Starting at the top of the list, go through each program and device and remove employee access. For procedures regarding specific programs, see [directory of procedures].
  3. Go to Active Directory and find employee information.
  4. Backup emails and save them to [directory] to be stored for a period of one year before deletion.
  5. Backup any information relating to patient care in appropriate directories. See [directory list] for proper placement.
  6. Disable user’s Active Directory account and change their password.
  7. Document time, date, and your name in the Employee Termination log to indicate all access it removed.
  8. Inform former employee’s supervisor when access removal is completed for verification.

Procedures should be as detailed as possible so that there is no ambiguity or confusion in what needs to be done. It allows newer employees to accomplish tasks they may not have performed before. There may also be multiple procedures related to the same policy depending on the duties of each person. Margret Amatayakul wrote an excellent guide to creating policies and procedures for the Journal of AHIMA (American Health Information Management Association).

Note: Both the Security Rule and the Privacy Rule require policies and procedures to be created. A company can combine relevant Security and Privacy standards into a single policy or create entirely separate policies for the Security and Privacy Rules. Each business should determine what is best for its employees.

The Importance of Employee Training in HIPAA

Once you have your policies and procedures written and accessible, the next vital step is to train employees on them. HIPAA requires all employees to be trained in the policies and procedures related to their job. This training includes everyone from the maintenance staff to the CEO. Each time a policy or procedure is updated, retired, or replaced, the affected staff must be informed and, if needed, new training should occur.

Of course, maintenance personnel and CEOs won’t need the same kind of HIPAA training, just as IT support doesn’t need the same training as a nurse. HIPAA doesn’t dictate the way training happens, only that it happens. This means big companies that can afford professional training materials can do so, but smaller companies may hold informational meetings, allowing each to train the way that is most effective and makes the most sense for them.

Suggestions For Employee Training

  • Go through your employees’ job descriptions and separate employees by the level of access they have to PHI.
  • Create training programs for each level of access and/or the duties required in the job description so each employee gets the training suited to their job.
  • Don’t overload employees with policies and procedures that don’t relate to their job.
  • Ensure all training includes how to access the company’s policies and procedures in case employees need to revisit or reference them.
  • Ensure all employees know who to contact if they have any questions.


Along with training employees, HIPAA also requires you have clear consequences for not following the written policies and procedures. The types of offenses should be clearly defined and the disciplinary action enacted for every infraction.

One way a company might dictate levels of disciplinary action would be to clarify whether a break in policy or HIPAA standard was accidental, made through negligence, or of malicious intent. This allows various consequences for the same infraction without being inconsistent. An example would be: a) an employee leaving a workstation unlocked because an emergency situation demanded they respond immediately, b) they consistently forget to lock their workstation even after being warned about it, or c) they intentionally leave a workstation unlocked to allow someone without access to view ePHI. While the problem is technically the same, they don’t all deserve the same consequences. As with everything else, all infractions and disciplinary actions need to be documented and retained for six years.

In 2018, the Health and Human Services Office of Civil Rights reported 279 breaches of PHI, each resulting in at least 500 individuals affected, though often the number was much higher. Policies and procedures may feel tedious to write, but they provide employees with the information necessary to do their job in a HIPAA compliant manner and could prevent a breach of PHI.

For help with developing clear and secure policies for your company’s software and devices, contact Anderson Technologies at 314.394.3001 or by email at info@andersontech.com.