Organize HIPAA Audits

Are you HIPAA compliant? Many organizations struggle to answer this question for good reason. HIPAA compliance is complicated. The good news? Once you understand the documentation you need and how to put it together, you’ll be able to answer that question with a confident “yes”. Ready to jump in? This bite-size guide will tell you what you need to know about organizing for HIPAA audits.

Why Do You Need To Organize for HIPAA Audits?

Before we talk about how to organize for HIPAA audits, it’s important to understand why this process is important. There are a few reasons why organizing documentation is a crucial part of becoming or staying HIPAA complaint. Here’s a quick look:

First, is to prepare the audit itself. Organizing your documentation is the key to avoiding any issues with compliance. If you have the documents on hand when the HHS comes knocking, you’re much less likely be fined. Beyond preparing for the audit the first time you get your documents together, this is also really important for the future. You’ll save yourself the stress of starting the organization process from the ground up when you need to add to or revise documentation.

The next thing to consider is your staff. Roles change and people move on to other opportunities. However, this doesn’t mean that new members of your team need to start from scratch. Having well-organized HIPAA documentation allows new staff to hit the ground running.

Finally, remember that this is all about security and your commitment to patients. The safety and privacy of their information should be a top priority. Having well documented and organized processes helps you ensure that you’re keeping data safe. This way, you don’t have to wonder if your organization is at risk.

How to Make Sure Your Organization Has The Right Documentation

If you’re feeling like your organization is behind the eight ball, don’t worry. Many organizations don’t know what to document or how to document it but this doesn’t have to remain a mystery. In general, you want to document everything related to Protected Health Information (PHI) at your practices. These documents should show what your status is today and what your plans are to continue compliance efforts in the future.

Here are some questions you should ask yourself and your team when you are gathering HIPAA documentation:

  • How do we currently handle security?
  • Do we have any vulnerabilities?
  • Have we trained our employees to understand HIPAA compliance?
  • Are our workstations secure?
  • What have we learned from becoming HIPAA compliant?

When you consider these questions, it’s likely that you’ll start to uncover and sort the types of documents you need. Remember, you want to focus on both where your organization is now and your plans for the future. As you walk through this process and start filing away the documents, you’ll also discover any holes in documentation that may exist. You can note these gaps for future reference.

What Documents Should Be Collected?

Before you can start organizing HIPAA documentation, you should have a full view of what documents you need. We covered some of this information in the first part of this series, but if you’re looking for specific ideas, here’s a list to put you on the right path.

  • Risk analysis
  • List of vendors
  • Agreements with business associates
  • List of staff members
  • Training logs and handbooks
  • List of devices
  • Future plans and goals
  • HIPAA compliant processes
  • Security breach response plan
  • PHI documentation diagram

Of course, there are many different kinds of documents that you can collect here. That said, starting here will help you create a robust collection of HIPAA documentation that will make the auditing process less stressful. Remember, you can choose the form your documentation takes, but it’s best to have physical or digital copies. Just because your staff knows your procedures, doesn’t mean you’re prepared for an audit.

Note: If your head is spinning because you don’t have all these documents, don’t panic. As mentioned above, you will likely find gaps in your documentation during this process. If this happens to you, take note of them and prioritize the creation of these documents.

How to Review and Organize HIPAA Documentation

Reviewing and organizing HIPAA information is a continuous process. Some healthcare organizations make the mistake of gathering all their documentation, giving it a quick glance and putting it away until HIPAA comes to mind again. This is a huge problem because it can lead to a disorganized mess of files that don’t actually meet the guidelines and can get you into serious trouble.

So, what should you do? Instead of looking at your HIPAA documentation once a year, make the process on-going. Dedicate time to assessing your security strategy. Review documents on a regular basis and revise or add to your documentation as needed. When you do this, the process becomes less overwhelming and you ensure that your organization is prepared in the event of an audit.

The most important thing to remember is that this information should be easily accessible. Follow a system that makes sense to you and can be followed by members of your staff or an auditor. As mentioned above, once you collect your documents and begin to file them, you should also create a PHI documentation diagram. This will display the thought process and flow that went in to organizing your documentation, making it easy to locate specific information later.

Wrapping Up

If you take one thing away from this post, it should be that reviewing and organizing HIPAA documentation doesn’t have to be complicated. Using this guide, you can start to put organize your documents at your own pace, and continue adding to your documentation as necessary. Starting on this process before a potential audit will save you a lot of time and headaches in the long run. Want to know more about how to prepare for HIPAA content audits? Keep an eye on our blog for the next part in this series.


Mark Elliott is a Best-Selling Author and CEO. His company, 3i International, helps you apply technology to improve performance and compliance. For over 25 years, Mark has been helping startups to Fortune 500 companies overcome the technology challenges they face. He develops strategies to analyze, manage, and adapt to the ever-changing technology landscape. A central focus has been security and HIPAA compliance. His experience includes preventing, detecting, and responding to hackers and threats. This keeps your organization safe from invasions while simultaneously meeting regulatory compliance.