7 Essential Steps to Create a HIPAA Compliance Checklist in 2025

Did you know healthcare ranks second among industries targeted by cyberattacks? About 20% of victims face breaches due to cloud misconfigurations.

To ensure proper compliance, refer to our comprehensive HIPAA Compliance Checklist regularly. (Need Help? Set up a Quick Call w/ the HIPAA Pros at CTMS)

Healthcare organizations and their business partners must protect sensitive patient information, not just to avoid fines. The HIPAA Security Rule sets national standards to safeguard electronic protected health information (ePHI). These standards require specific administrative, physical, and technical safeguards.

Mishandling patients’ PHI can have serious consequences. Organizations with breaches end up on OCR’s “Wall of Shame.” This wall publicly shows violations, penalties, and affected individuals’ count. These violations can get very pricey – OCR issues fines even for smaller breaches that don’t meet compliance requirements.

This HIPAA Compliance Checklist will guide you through crucial actions needed for compliance.

As you create your HIPAA Compliance Checklist, remember to revisit it periodically.

We created this complete guide to help you build a strong HIPAA compliance checklist for 2025. You’ll learn eight key actions needed to fulfill HIPAA mandates. This guide works if you’re new to compliance or want to improve your existing protocols. We cover everything from the three main HIPAA rules to risk analysis and proper documentation.

This step-by-step approach will give you the tools to protect sensitive healthcare data and avoid the most important consequences of non-compliance. Let’s start your journey toward full HIPAA compliance!

Understand What HIPAA Compliance Really Means

A detailed HIPAA Compliance Checklist is essential for maintaining standards.

Utilizing a HIPAA Compliance Checklist ensures all relevant rules are followed.

Your HIPAA Compliance Checklist should be kept up to date with current regulations.

Regular updates to your HIPAA Compliance Checklist are crucial for ongoing compliance.

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HIPAA compliance isn’t just another box to check—it’s a vital framework that protects sensitive patient information in today’s digital world. Let’s break down what HIPAA really means and the differences between its major components.

What is HIPAA and who needs to comply?

Congress enacted the Health Insurance Portability and Accountability Act (HIPAA) in 1996. This law set national standards for electronic healthcare transactions and data privacy. While HIPAA has five titles, most compliance work centers on Title II. This section deals with preventing healthcare fraud and abuse, administrative simplification, and medical liability reform.

Incorporate findings from your HIPAA Compliance Checklist into your organizational practices.

HIPAA creates federal standards to secure electronic protected health information (ePHI). These standards protect data’s confidentiality, integrity, and availability. Three main types of organizations must follow these rules:

Covered Entities must follow all HIPAA regulations, including:

Health plans (insurance companies, HMOs, Medicare, Medicaid)
Healthcare clearinghouses (entities that process nonstandard health information)
Healthcare providers who send health information electronically for transactions (e.g., claims, benefit eligibility inquiries, referral authorizations)

A healthcare provider becomes a covered entity if they send health information electronically for HIPAA transactions. Using email alone doesn’t make a provider a covered entity—the transmission must link to specific standard transactions.

Business Associates have HIPAA duties too. These organizations or individuals work with protected health information for covered entities through:

Claims processing
Data analysis
Billing services
Legal services
Consulting
Administrative assistance

The HITECH Act of 2009 made business associates directly responsible for HIPAA violations, beyond their contractual obligations with covered entities.

The difference between Privacy Rule and Security Rule

The HIPAA Privacy Rule and Security Rule work together but serve different purposes. Each has specific requirements you need to know for proper compliance.

Ensure your HIPAA Compliance Checklist aligns with industry best practices.

The Privacy Rule protects people’s identifiable health information in all forms—paper, electronic, and oral. This rule:

Limits PHI use and disclosure
Lets patients check and copy their health records
Makes covered entities provide patients with a Notice of Privacy Practices
Covers all forms of protected health information

The Privacy Rule takes a broader approach and focuses on patient rights and proper health information handling.

The Security Rule specifically guards electronic PHI (ePHI). It requires proper administrative, physical, and technical safeguards. Here are the three main types:

Administrative safeguards: These include policies and procedures that protect ePHI, like risk analysis, staff training, and contingency planning
Physical safeguards: These control physical access to ePHI through facility restrictions, workstation security, and device controls
Technical safeguards: These include access controls, audit controls, integrity controls, and secure ePHI transmission

The main difference lies in scope—the Privacy Rule protects all PHI forms, while the Security Rule focuses on electronic PHI and its technical protection.

These differences matter when you create your HIPAA compliance checklist. CTMS helps businesses handle these complex requirements with custom IT solutions that meet both Privacy and Security Rule standards. Our healthcare compliance expertise lets you focus on patient care while we manage the technical side of HIPAA compliance.

Do you need help figuring out which HIPAA requirements apply to your organization? Visit https://www.ctmsit.com/ to get a free HIPAA compliance assessment and find out how our IT solutions can protect your patient data and keep you compliant.

Identify What Data You Need to Protect

A clear understanding of data that needs protection is the first step in safeguarding patient information. Healthcare providers who want to build a working HIPAA compliance checklist should identify information that falls under regulatory protection and its location in their organization.

What qualifies as PHI and ePHI

Protected Health Information (PHI) includes more than just medical records. HIPAA regulations define PHI as any individually identifiable health information that relates to:

An individual’s past, present, or future physical or mental health condition
The provision of healthcare to an individual
The payment for healthcare services
Any information that could identify the individual or provide a reasonable basis to identify them

Electronic Protected Health Information (ePHI) is PHI in electronic form. This difference is significant because the HIPAA Security Rule specifically governs ePHI protection, while the Privacy Rule covers all forms of PHI whatever the format.

Personal identifiers make information “identifiable”. HIPAA defines 18 specific identifiers that create PHI when combined with health information:

To achieve full compliance, utilize the HIPAA Compliance Checklist as a roadmap.

Discover how a HIPAA Compliance Checklist can enhance your compliance program.

For comprehensive insights, refer to our HIPAA Compliance Checklist.

Each entry in your HIPAA Compliance Checklist should be actionable and measurable.

Names
Geographic subdivisions smaller than a state (except for first 3 digits of ZIP codes in certain cases)
Dates related to an individual (except year) including birth date, admission date, discharge date
Telephone and fax numbers
Email addresses and social media handles
Social Security numbers
Medical record numbers and health plan beneficiary numbers
Account and certificate/license numbers
Device identifiers and serial numbers
Biometric identifiers (fingerprints, voiceprints)
Full-face photographs and comparable images
Any other unique identifying characteristic or code

Information without these identifiers or properly de-identified data isn’t considered PHI and stays outside HIPAA regulations.

Common data sources in small businesses

Small healthcare organizations don’t deal very well with identifying all PHI locations. Our work with Ohio businesses shows these common repositories of protected information:

Electronic sources:

Electronic Health Record (EHR) systems
Practice management software
Email communications containing patient information
Billing and payment processing systems
Mobile devices (phones, tablets) used for patient care
Cloud storage services containing healthcare data
Backup systems and disaster recovery solutions

Physical sources:

Paper medical records and charts
Lab results and diagnostic reports
Intake and registration forms
Billing statements and insurance claims
Appointment schedules and patient logs
Fax machines and printouts

A single item combined with health information can constitute PHI. To cite an instance, see a patient’s email address stored with their treatment information – this qualifies as PHI and needs protection.

Why knowing your data flow matters

Your organization’s HIPAA compliance depends on understanding information movement. Data flow represents PHI’s complete lifecycle—how it’s created, received, managed, transmitted, and disposed of within your systems.

Data flow mapping reveals:

PHI entry points in your organization
Access permissions at each stage
Movement between departments or systems
Exit points from your organization
Weak spots in your protection measures

Healthcare compliance experts note that “Without clear understanding of how information moves in and out of your systems, you can’t effectively secure it”. This mapping process protects you from data breaches that can get pricey and damage your reputation.

CTMS helps Ohio healthcare providers map their data flow and identify all PHI touchpoints. Our specialized IT solutions protect your sensitive information throughout its lifecycle. Do you need help identifying data that requires protection in your organization? Visit https://www.ctmsit.com/ to get a full picture of HIPAA data—we’ll help build solid foundations for your compliance program.

Perform a HIPAA Risk Assessment

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A HIPAA risk assessment isn’t just about following regulations—it’s the life-blood of your compliance program. The HIPAA Security Rule demands organizations to “conduct an accurate and full picture of potential risks and vulnerabilities to the confidentiality, integrity, and availability of electronic protected health information”.

How to conduct a simple risk analysis

Use our HIPAA Compliance Checklist to guide your training and policy development.

Your security activities are built on risk analysis foundations. Here’s a clear approach to your assessment:

Prioritize tasks on your HIPAA Compliance Checklist based on risk assessments.

Define the scope – Your original task involves identifying all systems that create, receive, maintain, or transmit ePHI. Note that electronic media ranges from single workstations to complex networks connected between multiple locations.
Gather relevant data – You’ll need information about ePHI storage through interviews, documentation reviews, and system analysis. Small providers might review just one department, while larger organizations could need multiple physical locations and systems.
Identify threats and vulnerabilities – Your assessment should cover human threats (employees, hackers, commercial rivals) and environmental/natural threats relevant to your location. Human threats create the greatest concern because they happen more often.
Evaluate current security measures – List your existing safeguards and check if they’re properly configured and used. This step shows whether your current measures protect ePHI adequately.
Determine risk levels – Look at how likely threats are to occur and their potential impact. This helps you focus on vulnerabilities that need immediate attention.

Tools to help with HIPAA IT compliance checklist

Risk assessment doesn’t have to be a solo journey. Several resources make this process easier:

The NIST HIPAA Security Toolkit Application helps organizations understand Security Rule requirements better and implement them operationally. Covered entities of all sizes find this resource valuable.

Small and medium-sized practices benefit from the Security Risk Assessment (SRA) Tool. The Office of the National Coordinator for Health Information Technology and HHS Office for Civil Rights created this downloadable guide that walks through the risk analysis process.

The HIPAA Security Series papers offer detailed guidance on risk analysis tools and methods. These resources explain requirements and solutions clearly.

Ohio healthcare providers don’t deal very well with technical compliance requirements. CTMS offers specialized IT solutions with guided risk assessments that catch vulnerabilities early.

Documenting vulnerabilities and threats

The Security Rule requires proper documentation. Your risk analysis records should show:

All identified threats and vulnerabilities with their likelihood ratings
What happens if threats become real
Risk levels and planned fixes
Current security measures and how well they work

Documentation drives your risk management process. While you can choose your format, records must show compliance during an audit.

Risk analysis needs regular updates, not just one-time attention. Organizations vary in their update schedules—some yearly, others every two or three years.

Do you need help with your HIPAA risk assessment? Visit https://www.ctmsit.com/ for expert guidance. Our Ohio-based team specializes in healthcare IT compliance to protect patient data and avoid penalties that can get pricey.

Implement the Right Safeguards

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Your next significant step toward HIPAA compliance after risk assessment involves setting up proper safeguards. The HIPAA Security Rule requires covered entities and business associates to implement three types of protections. These protections work together to create a complete security program.

Administrative safeguards: policies and training

Administrative safeguards are the foundations of your HIPAA compliance program and make up more than half of all HIPAA Security Rule requirements. These safeguards include “administrative actions, policies, and procedures to manage the selection, development, implementation, and maintenance of security measures to protect ePHI”.

Your administrative safeguards must include:

A Security Officer who develops and runs your security program
Regular risk assessments (covered in the previous section)
A sanctions policy for staff who break security rules
Security awareness training for all team members and leadership
Security incident procedures to spot, handle, and document possible breaches
A contingency plan for system emergencies

Your workforce security procedures should ensure that only authorized staff can access ePHI. This prevents unauthorized personnel from getting access to sensitive data.

Physical safeguards: access and device control

Physical safeguards protect “electronic information systems and related facilities from natural and environmental hazards, and unauthorized intrusion”.

Good physical safeguards control facility access, secure ePHI workstations, and manage devices and media. Workstation security needs careful placement of screens away from public view, especially during telehealth sessions.

Your organization needs clear policies to track hardware and electronic media with ePHI. This includes documented protocols for removing ePHI from electronic media before reuse. You also need proven methods to destroy devices permanently.

Technical safeguards: encryption and access logs

Technical safeguards use technology and related policies to protect ePHI. These safeguards follow five key standards:

Access Control: Technical policies must ensure only authorized staff can access ePHI. This happens through unique user IDs, emergency access procedures, automatic logoff, and encryption tools.

Audit Controls: Hardware, software, or procedural mechanisms should track and review activity in ePHI information systems.

Integrity Controls: Authentication mechanisms verify that ePHI stays intact and safe from tampering.

Authentication Controls: Multi-factor authentication helps verify users’ identity before they access ePHI.

Transmission Security: Encryption protects ePHI during electronic transmission from unauthorized access.

CTMS helps Ohio healthcare providers set up these vital safeguards. Our team knows HIPAA compliance’s technical requirements and creates custom solutions to protect patient data while maintaining smooth operations. Visit https://www.ctmsit.com/ for a complete HIPAA compliance assessment if you need help with safeguards.

Create and Maintain HIPAA Documentation

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Documentation forms the foundations of every successful HIPAA compliance program. Your organization must maintain complete records that show ongoing compliance efforts, beyond implementing proper safeguards. Here’s what you need to know about required documentation and the quickest way to manage this vital part of your HIPAA compliance checklist.

What to document and how long to keep it

The HIPAA Security Rule clearly states documentation retention requirements. You must keep all HIPAA-related documents minimum of six years from their creation date or when they were last effective, whichever comes later. This means a policy created in 2025 and updated in 2027 needs retention until 2033—six years after it was last effective.

Essential documentation you must maintain:

Policies and procedures that comply with HIPAA requirements
Security incident records and breach notifications
Risk assessments and risk management plans
Employee training materials and attestations
Business Associate Agreements
Access control logs and audit trails

HIPAA doesn’t define medical record retention periods. State laws govern these periods, which usually range from 5-10 years based on your location. Organizations that submit Medicare cost reports must keep records five years after closure. Medicare managed care providers need their records for 10 years.

Templates and tools to simplify the process

Ohio healthcare providers often find creating HIPAA documentation from scratch overwhelming. CTMS helps you access resources that make this process easier.

HIPAA policy templates give you these advantages:

Standardized language and formatting create uniform policies
Complex regulations become understandable sections
You save time by avoiding starting from zero
Your commitment to patient information protection becomes clear

Vendors provide customizable templates that match your organization’s needs. These templates cover Privacy, Security, and Breach Notification Rules for both covered entities and business associates.

CTMS provides specialized IT solutions that merge with your existing systems. We help Ohio healthcare providers implement document management software that protects PHI and makes compliance simple.

Do you need help with your HIPAA documentation? Visit https://www.ctmsit.com/ to get a free consultation. Our Ohio-based experts will create a documentation system that keeps you ready for audits and compliant with regulations.

Prepare for Breaches and Stay Audit-Ready

No HIPAA compliance program can fully prevent data breaches, no matter how reliable it is. Healthcare organizations today need to prepare for potential incidents just as much as they work to prevent them. Let’s get into proper breach handling and staying ready for audits.

Breach notification requirements

The HIPAA Breach Notification Rule requires covered entities to alert affected individuals, the HHS Secretary, and sometimes the media when unsecured PHI is breached. Different timelines apply based on the breach size:

Individual notifications: Send these within 60 days of discovery through first-class mail or email (if individuals agree to electronic notices)
HHS Secretary notifications: Report breaches affecting 500+ people within 60 days. Submit smaller breaches in an annual report 60 days after the year ends
Media notifications: Alert media when breaches affect more than 500 residents in one state or jurisdiction

Each notification needs specific details like what happened, types of PHI involved, steps people should take, and who to contact.

How to respond to incidents quickly

A documented incident response plan plays a vital role in managing breaches. The plan works in three key phases:

The containment phase isolates affected systems to stop unauthorized access. Eradication removes all attack traces while keeping evidence for later analysis. The recovery phase gets systems and data back to their original state.

Document every response action you take. This helps with compliance and makes future incident handling better.

Tips to stay ready for OCR audits

OCR audits can happen anytime. Your organization needs to stay prepared always. Here’s what you can do:

Train your staff on HIPAA policies and keep records of all sessions
Do yearly risk assessments to spot and fix weak points
Pick Privacy and Security Officers who can enforce compliance
Create and test your detailed compliance plan regularly
Update policies to match your current systems and team

CTMS knows how challenging HIPAA compliance can be for Ohio healthcare organizations. Our IT solutions help create reliable breach response plans and keep you audit-ready without affecting patient care. Need guidance with breach preparation or OCR audits? Visit https://www.ctmsit.com/ or click here, for a free compliance consultation. We’ll help protect your patients and practice.

Conclusion

Take Action on Your HIPAA Compliance Experience

HIPAA compliance demands dedication and constant effort. This piece outlines the key steps you need to protect patient information and meet regulatory requirements. The Privacy and Security Rules are the foundations of compliance, but effective protection needs more than simple knowledge.

Your security efforts should focus on identifying critical data that needs protection. Regular risk assessments help spot vulnerabilities before they become issues. These assessments can reduce your exposure to potential breaches by a lot.

Administrative, physical, and technical safeguards create a detailed security framework together. Good documentation proves your compliance efforts during audits. A solid breach response plan prepares you for unexpected scenarios.

Your healthcare practice shouldn’t stay exposed to data breaches that can get pricey. CTMS IT provides expert HIPAA compliance solutions, proactive cybersecurity, and up-to-the-minute threat detection. You can focus on care without compliance concerns. ✅ 24/7 Monitoring | ✅ Fast 15.6-Minute Response Time | ✅ Proven Compliance Expertise 👉 Schedule Your Free HIPAA Compliance Assessment Today!

CTMS understands Ohio healthcare providers’ unique compliance challenges. Our expert team creates custom HIPAA compliance solutions that protect patient data and keep operations smooth. We can help with risk assessments, safeguard implementation, and audit preparation. Our expertise guides you through each step.

Want to improve your HIPAA compliance program? Visit https://www.ctmsit.com/ today for a free consultation with our Ohio-based team. We’ll handle the technical compliance details while you focus on providing quality patient care.

FAQs

Q1. What are the key components of a HIPAA compliance checklist? A HIPAA compliance checklist typically includes understanding HIPAA rules, conducting risk assessments, implementing safeguards, developing policies and procedures, designating compliance officers, providing staff training, and establishing breach notification plans.

Q2. How often should HIPAA risk assessments be conducted? HIPAA risk assessments should be conducted regularly, with the frequency depending on your organization’s circumstances. Some perform them annually, while others do them bi-annually or every three years. The key is to ensure they’re done consistently to identify new vulnerabilities.

Q3. What are the three main types of safeguards required by HIPAA? HIPAA requires three main types of safeguards: administrative safeguards (policies and procedures), physical safeguards (facility access controls and device security), and technical safeguards (encryption, access controls, and audit logs).

Q4. How long must HIPAA-related documentation be retained? HIPAA-related documentation must be retained for a minimum of six years from the date of creation or when it was last in effect, whichever is later. This includes policies, procedures, risk assessments, and training records.

Q5. What are the breach notification requirements under HIPAA? HIPAA breach notification requirements vary based on the scope of the breach. For breaches affecting 500 or more individuals, notifications must be sent to affected individuals within 60 days, to the HHS Secretary within 60 days, and to the media if it affects more than 500 residents of a state or jurisdiction.

Your HIPAA Compliance Checklist can serve as a training tool for new staff.

Developing a responsive HIPAA Compliance Checklist is key to effective management.

Review your HIPAA Compliance Checklist regularly to ensure it remains relevant.

Incorporating updates into your HIPAA Compliance Checklist enhances reliability.

A complete HIPAA Compliance Checklist aids in audit preparedness.

Document your progress using the HIPAA Compliance Checklist for clarity.

Your HIPAA Compliance Checklist should reflect the unique needs of your organization.

Refining your HIPAA Compliance Checklist regularly keeps it effective.

7 Essential Steps to Create a HIP...