Independent thinking. Informed defence.

CISO Times

Intelligence for the people behind the defence.

The CISO Decision Brief

What it says

(a) Standard: Policies and procedures. Implement reasonable and appropriate policies and procedures to comply with the standards, implementation specifications, or other requirements of this subpart, taking into account those factors specified in § 164.306(b)(2)(i), (ii), (iii), and (iv). This standard is not to be construed to permit or excuse an action that violates any other standard, implementation specification, or other requirements of this subpart. A covered entity or business associate may change its policies and procedures at any time, provided that the changes are documented and are implemented in accordance with this subpart.

HIPAA, the United States rules protecting health information, § 164.316(a)

What is in the packs for this

From HIPAA Security Rule Readiness. Each one helps with this requirement.

  • Excel

    Security Rule Safeguard Register

    Its Framework References cite this section. Lists the 22 Security Rule standards and their 41 implementation specifications in plain words, required or addressable, with an owner and the evidence to keep.
  • Word

    Security Risk Analysis Method

    Its Framework References cite this section. Sets out a repeatable method for the security risk analysis: the inventory of electronic patient information, threats, vulnerabilities, ratings and the signed record.
  • Excel

    HIPAA Documentation & Evidence Checklist

    Its Framework References cite this section. Lists the documents and records to keep ready, the paragraph of the Rule behind each, and how long each must be kept.
  • Excel

    HIPAA Gap & Remediation Tracker

    Its Framework References cite this section. Tracks the gaps found against the readiness items, with priority, owner, deadline and status.
  • Excel

    HIPAA Security Rule Readiness Self-Assessment

    Its Framework References cite this section. Rates readiness against the Security Rule items and returns the blocking gaps, in counts and with no score.

Text: 45 CFR Part 164, from the Electronic Code of Federal Regulations (eCFR) as it stood on 6 October 2026.