This policy is listed for reference only and should be reviewed with your lawyer before implementing them into daily practice. We are not lawyers and are not providing any legal advice. View our legal disclaimer.

Security Management Process: Risk Analysis (Required)

Reference: 45 CFR 164.308(a)(1)

Last Updated: October 24, 2024

Purpose

The purpose of the Risk Analysis Policy is:

To determine potential risks to the confidentiality, integrity and availability of electronic patient health information (EPHI).
To evaluate cost-effective security measures.
To determine a basis for determination of acceptable level of risk based on available resources.
To assist in the identification and implementation of risk management policies to reduce the risks uncovered by security inspections.

Policy

Procedure: In order to assess and prioritize tasks regarding this policy we will:

Perform and maintain an initial Internal Security Checklist to establish a baseline of security risks.
Variables to consider during the risk assessment should covered the following areas:
- Asset inventory,
- Data criticality analysis,
- Threat assessments,
- Determination of risk exposures, and
- Development of a risk management plan or similar plan of action that addresses and documents actions taken.
Maintain a written record of the analysis/assessment for 6 years.
Submit the risk assessment findings and the risk management plan to the appropriate parties within 30 days of concluding their assessment.
Whenever possible, an objective third party shall be contracted to conduct the initial and subsequent Risk Analysis.

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