HIPAA Policy and Procedure Requirements

What Should Be in Place?

When it comes to HIPAA compliance, there’s one truth that catches many organizations off guard: if it’s not documented, it doesn’t count.

HIPAA doesn’t just expect you to protect patient data—it expects you to have clear, written policies that explain how you do that. Those policies must be followed, reviewed, and updated regularly. 

So, what exactly does HIPAA require when it comes to policies and procedures? What should be in place? And how do you manage it all without drowning in documentation? 

Let’s break it down—and explore how Medcurity can make it simple.

What Does HIPAA Require?

The HIPAA Privacy, Security, and Breach Notification Rules all require covered entities and business associates to implement policies and procedures that align with the standards in each rule. 

That means your organization must: 

  • Develop and implement written policies that address how you safeguard protected health information (PHI) 
  • Review those policies periodically 
  • Update them as needed to reflect changes in your environment or regulations 
  • Ensure your staff is trained on what the policies say and how to follow them 

It’s not enough to download a few templates or write something once and forget it. These documents should reflect what’s happening in your organization—and guide what should happen next. 

Key Policies Every HIPAA-Covered Organization Should Have

Here’s a list of the foundational policies you should have in place: 

Privacy Rule Policies: 

  • Use and disclosure of PHI 
  • Minimum necessary use 
  • Patient rights (access, amendment, accounting of disclosures) 
  • Authorization requirements 
  • Notice of Privacy Practices 


Security Rule Policies:
 

  • Security Risk Analysis procedures 
  • Access control and authentication 
  • Password and device management 
  • Workstation use and security 
  • Mobile device and remote access policy 
  • Workforce security and termination procedures 
  • Contingency planning and data backup 


Breach Notification Policies:
 

  • Breach investigation and response 
  • Risk assessment procedures 
  • Notification timelines and templates 
  • Documentation and mitigation procedures 


Training and Sanctions:
 

  • Workforce training policy 
  • Sanction policy for non-compliance 
  • Complaint handling process 


If you’re missing any of these, or your policies haven’t been reviewed recently, now’s the time to act.
 

Common Challenges (and How to Overcome Them)

  • Outdated policies: HIPAA expects periodic review. If it’s been years—or even months—since your last update, that’s a risk. 
  • Inconsistent enforcement: Your policies need to match what your team is actually doing. If they don’t, you could face penalties even if no breach occurs. 
  • Missing documentation: Verbal procedures or “tribal knowledge” doesn’t meet HIPAA standards. Everything must be documented and accessible. 
  • Lack of training: Policies mean little if your staff isn’t aware of them—or doesn’t know how to follow them. 

How Medcurity Helps You Stay on Track

Managing policies and procedures manually can feel like a full-time job. Medcurity makes it easier, faster, and fully integrated with your broader HIPAA compliance efforts. 

Here’s how we help: 

  • Pre-built, customizable templates: We provide comprehensive policy templates aligned with HIPAA requirements—ready to tailor to your organization. 
  • Centralized policy library: Store all your documents in one secure location, accessible whenever you need them. 
  • Review and update tracking: Set reminders for periodic policy reviews and track version history, so nothing falls through the cracks. 
  • Staff assignments and attestations: Assign policies to team members, track acknowledgments, and document who’s seen what. 
  • Audit-ready documentation: Everything is organized, timestamped, and ready to present if you’re ever audited. 

Whether you’re building from scratch or tightening up an existing compliance program, Medcurity helps you turn policy management into a streamlined, repeatable process.

Your Policies Should Reflect Your Practices

HIPAA compliance is more than having a binder on a shelf. Your policies should reflect your current processes—and your team should know how to follow them. It’s about building a culture of privacy and security, not just checking boxes. 

Medcurity is here to help you create, manage, and maintain HIPAA policies and procedures that not only meet the standard—but support your mission. 

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