HIPAA Documentation: What You Need to Know

HIPAA Documentation: What You Need to Know

If you own a healthcare center or provide services to one, you understand how critical HIPAA compliance is. Much of your HIPAA compliance procedure should be spent documenting what you’ve accomplished. This procedure, also known as documentation, is tedious and is absolutely necessary for HIPAA compliance. Documentation assists others in understanding what has been done, what remains to be done, and where the problem areas are.

This blog article aims to educate you about everything you must know to complete your HIPAA documentation process, why you should do it, what the requirements are, and how to maintain your HIPAA documentation.

What is HIPAA Documentation?

HIPAA documentation is an amalgamation of policies, procedures, guidelines, controls and monitoring process under the HIPAA Security and Privacy Rules. 

This is an essential procedure that allows you to obtain visible, verifiable proof or evidence (VDE). Documentation can be created electronically, using HIPAA-compliant software, or on non-electronic media, such as paper. 

Why Should You Document For HIPAA Compliance?

A healthcare company with a comprehensive documentation management system will find its HIPAA compliance implementation process effectively meaningful. When done correctly, documentation establishes a baseline security standard for every process, workforce member, and system in your organization.

There are three major reasons why appropriate documentation is still critical for healthcare organizations seeking HIPAA compliance. Here are the following:

  • Creating a System: By documenting and organizing your policies, processes, procedures, you create a system that your team members can refer to for guidance.
  • HHS audit Readiness: If the US Department of Health and Human Services (HHS) calls to audit, appropriate documentation is a must to show that your company is compliant by maintaining records and the policies, procedures and processes that you’re documenting are actually being implemented and followed.
  • Third Party Security audit Readiness: With third party HIPAA audits, you can establish your credibility further that you are compliant with HIPAA, hence, having an established   documentation system is one of the best ways for security auditors to learn more about your company and verify.

What are the HIPAA Documentation Requirements?

Refer to these HIPAA documentation standards if you are a covered entity (CE) or business associate (BA).

  • Covered entities must record their designation in writing or electronically. 
  • CEs and BAs must keep track of record authorizations for each patient. 
  • Covered entities must designate and record parts of health components (c). 
  • If a standard adopted under 164.308, 164.310, 164.312, 164.314, or 164.316 contains implementation specifications, CE and BA must document why the specification is not required to be implemented. 
  • According to 164.316 (b) (2), a CE and BA must review or modify security measures required to properly protect electronically protected health information (ePHI) and update the relevant documents. 
  • CE and BA must document security incidents and their results. 
  • Any agreement and assurance must be documented by covered organizations in a Business Associate Agreement (BAA).
  • Implement policies or processes to record corrections or updates to a practice’s physical security components. 
  • According to 164.306, CEs and BAs must keep policies and processes linked to this subpart in writing or electronically. Furthermore, activities or assessments that must be recorded must be marked as a written record of the activity or assessment. Keep this document for six years from the date it was created or when it went into force. 
  • If a PHI breach affects fewer than 500 people, covered entities must maintain a record of it. 
  • If a law enforcement officer informs a CE or BA orally that a notice or posting would impede a criminal investigation, the CE or BA must record the remark. 
  • Plan sponsors must properly record the distinction between themselves and group health plans. 
  • According to 164.530, CEs must document and keep signed authorizations.
  • CEs must acquire study documentation from the researcher regarding the death of the individuals in question.
  • CEs may designate health information not to be PHI, and CEs must document the method used by an expert to determine the same in such instances. 
  • Healthcare providers must acquire and document a written acknowledgment of receipt of the notice specified in (c) (2). If it cannot be obtained, attempt to document the efforts made to obtain it. 
  • CEs must comply with the notice rules outlined in 164.530 (j). 
  • Following 160.530, CEs must record a restriction (j). 
  • CEs must document and retain the titles of those who receive and handle individual requests for amendments. 
  • A CE must document the data needed for PHI disclosure, written accounting given to individuals under section 164.528, and the title of individuals who receive and process accounting requests. 
  • A CE must keep records of administrative needs and training. 
  • CEs must record all complaints received. 
  • CEs must document sanctions imposed on employees who violate HIPAA privacy rules. 

How to Maintain HIPAA Documentation For Your Healthcare Organization?

The method for monitoring whether your organization is continuously compliant with the HIPAA guidelines should enable you to track and even produce visible, demonstrable evidence (VDE) per all HIPAA regulations. You must have the following to accomplish this:

  • A thorough grasp of all requirements that apply to your facility. 
  • For each of these requirements, you must be able to create VDE. 
  • Every prerequisite should be trackable at the granular level. 
  • If you cannot create VDE for some reason, you must devise a strategy to do so. 

As previously stated, both hard copies and electronic document maintenance methods are acceptable. However, electronic formats are better due to their ease of use and long-term viability. 

You must continuously revise and add to your HIPAA document collection to keep it current.

The maintenance of documentation should be an ongoing component of your overall strategy.

HIPAA Compliance With Akitra!

Establishing trust is a crucial competitive differentiator when courting new SaaS businesses in today’s era of data breaches and compromised privacy. Customers and partners want assurances that their organizations are doing everything possible to prevent disclosing sensitive data and putting them at risk, and compliance certification fills that need.

Akitra offers an industry-leading, AI-powered Compliance Automation platform for SaaS companies. Using automated evidence collection and continuous monitoring, together with a full suite of customizable policies and controls as a compliance foundation, our service helps customers become certified for HIPAA along with other frameworks like SOC 1, SOC 2, ISO 27001, ISO 27701, ISO 27017, ISO 27018, ISO 13485, GDPR, PCI DSS, FedRAMP, NIST 800-53, NIST 800-171, NIST CSF, CMMC, and other specific frameworks such as CIS AWS Foundations Benchmark, etc. Our compliance and security experts will also provide customized guidance to navigate the end-to-end compliance process confidently. 

The benefits of our solution include enormous savings in time, human resources, and cost savings—including discounted audit fees with our audit firm partners. Customers achieve compliance certification fast and cost-effectively, stay continuously compliant as they grow, and can become certified under additional frameworks using a single compliance automation platform.

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