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: Risk Analysis (Required)

Reference: 45 CFR § 164.308(a)(1)
Last Updated: July 5, 2023


Goal: Conduct an accurate and thorough assessment of the potential risks and vulnerabilities to the confidentiality, integrity, and availability of electronic protected health information held by the covered entity.

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.


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

  • Perform and maintain an initial Internal Security Checklist (Attachment A) to establish a baseline of security risks.
  • Perform, as identified in the appropriate security risk checklist (Attachment B), the necessary inspections to ensure compliance with the HIPAA Security policies.
  • Develop and update policies of systematic review and reporting of all incidents.
  • Maintain metrics to track patient complaints regarding security and ePHI.
  • Develop and maintain policies to deal with inquiries from governmental agencies, attorneys, consumer advocate groups, reporters and the media.
  • Develop and update as needed policies to comply with all applicable government regulations.
  • Analyze and assess effectiveness of the risk management program on an annual basis.
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