HIPAA Security Risk Analysis: What OCR Expects and Why Most Practices Fail the Audit

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November 3, 2026 - 07:40

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HIPAA Security Risk Analysis: What OCR Expects and Why Most Practices Fail the Audit

By the DoctorsManagement Compliance Team

Ask a practice administrator whether the practice has completed its HIPAA security risk analysis, and the answer is usually yes. Ask to see it, and the answer often changes. Sometimes it is a vendor questionnaire completed three years ago. Sometimes it is a checklist with every box marked “yes.” Sometimes it is a MIPS attestation that was clicked without anyone producing a document behind it.

None of those satisfy the regulation, and the Office for Civil Rights (OCR) at the U.S. Department of Health and Human Services knows it. Failure to conduct an accurate and thorough risk analysis is among the most frequently cited findings in OCR’s HIPAA enforcement actions, and since October 2024 OCR has run a dedicated enforcement effort, the Risk Analysis Initiative, aimed at exactly this deficiency. By mid 2026, that initiative had produced 14 enforcement actions, including settlements with small physician practices.

This guide explains what the Security Rule actually requires, why the most common approaches fail, the methodology OCR expects to see, how often the analysis must be updated, how it connects to MIPS, and what the pending Security Rule overhaul would change. It is written for compliance officers, practice administrators, and IT managers who need an analysis that will hold up when someone asks to see it.

What the HIPAA Security Risk Analysis Requires

The HIPAA Security Rule requires every covered entity and business associate to:

Conduct an accurate and thorough assessment of the potential risks and vulnerabilities to the confidentiality, integrity, and availability of electronic protected health information held by the covered entity or business associate.

That requirement appears at 45 CFR 164.308(a)(1)(ii)(A). It is the first implementation specification in the Security Rule’s first administrative safeguard, and for good reason: every other security decision a practice makes is supposed to flow from it.

Four Words That Matter

Accurate. The analysis must reflect how the practice actually operates today, not how a template assumes a practice operates.
Thorough. It must cover all electronic protected health information (ePHI) the practice creates, receives, maintains, or transmits, wherever it lives.
Risks and vulnerabilities. It must identify what could go wrong and where the practice is exposed, not simply confirm which policies exist.
Confidentiality, integrity, and availability. It must address all three. A practice that considers only unauthorized access and ignores ransomware, system failure, or data corruption has addressed one third of the requirement.

Risk Analysis Is Paired with Risk Management

The very next specification, 45 CFR 164.308(a)(1)(ii)(B), requires the practice to implement security measures sufficient to reduce identified risks and vulnerabilities to a reasonable and appropriate level. Identifying risks and then doing nothing about them is not compliance. OCR treats the two requirements as a pair, and enforcement actions frequently cite both.

The Rule Is Scalable, but Not Optional

The Security Rule is intentionally flexible. Under 45 CFR 164.306(b), a practice may consider its size, complexity, technical capabilities, the cost of security measures, and the probability and criticality of potential risks when deciding how to comply. That flexibility shapes how elaborate the analysis needs to be. It does not exempt a solo practice from performing one.

Why the Security Risk Analysis Matters More Than Ever

OCR’s Risk Analysis Initiative

OCR introduced its Risk Analysis Initiative in October 2024, tying the risk analysis requirement directly to defense against ransomware and other cyberattacks. The initiative continued under the current administration, and by April 2025 it had produced eight settlements totaling nearly $900,000. By July 2026, OCR had announced its 14th action under the initiative.

The settlements are not limited to hospitals and health systems. Recent enforcement actions citing risk analysis failures have involved a small New York neurology practice, a Michigan surgical group, a women’s health group, imaging providers, and an ambulatory surgery center. Settlement amounts for small practices have ranged from a few thousand dollars to several hundred thousand, and nearly every resolution includes a multi year corrective action plan requiring OCR monitoring, a new risk analysis, revised policies, and workforce training. For a small practice, the cost of the corrective action plan often exceeds the payment itself.

Ransomware Has Changed the Stakes

Most OCR investigations begin with a breach report, and most large breaches today involve hacking or ransomware. When OCR investigates a breach, the first document it typically requests is the risk analysis in place before the incident. If that analysis did not exist, was incomplete, or did not identify the vulnerability the attacker exploited, the practice faces two problems at once: the breach itself and a documented compliance failure that preceded it.

MIPS Makes It a Payment Issue

For clinicians participating in the Merit-based Incentive Payment System, the security risk analysis is a required measure in the Promoting Interoperability performance category. As discussed below, failing to complete it does not merely cost a few points. It zeroes out the entire category.

Risk Analysis, Risk Assessment, Gap Analysis, and Audit: Clearing Up the Terms

Much of the confusion around the SRA comes from vocabulary. The terms below are often used interchangeably, but they describe different things.

Term	What It Is	What It Is Not
Security risk analysis	The HIPAA required process of identifying threats and vulnerabilities to ePHI and rating the resulting risk	A list of policies the practice has adopted
Security risk assessment	Commonly used as a synonym for risk analysis; the HHS tool uses this name	A different legal requirement
HIPAA gap analysis	A comparison of the practice’s policies and safeguards against each Security Rule standard	A substitute for the risk analysis, though it can feed into one
Compliance audit	A review of whether the practice follows its own policies	A forward looking assessment of risk
Healthcare compliance risk assessment	A broader review of billing, coding, regulatory, and operational compliance risk	An analysis of ePHI security risk

A gap analysis answers the question “Do we have the required safeguards?” A risk analysis answers the question “What could actually happen to our ePHI, how likely is it, and how bad would it be?” OCR requires the second question to be answered. For the broader operational and billing side of compliance, see our separate framework for healthcare compliance risk assessments.

Why Most Practices Fail

When OCR finds a risk analysis deficient, the problem is rarely that the practice was negligent about security in general. It is usually one of a handful of recurring patterns.

The Analysis Was Never Performed

This remains the most common finding. Many practices believe their EHR vendor, IT contractor, or billing company performs the risk analysis for them. Vendors may perform their own analyses for their own systems, but the obligation to analyze the practice’s environment belongs to the practice.

A Checklist Was Mistaken for an Analysis

A list of questions answered yes or no (“Do you have a password policy?”) documents the existence of safeguards. It does not identify threats, evaluate likelihood and impact, or assign a risk level. It is a gap analysis at best.

The Scope Was Incomplete

A risk analysis that covers the EHR but ignores the patient portal, the fax server, the imaging equipment, the email system, the backup appliance, laptops used at home, the phone system that records voicemail, and the cloud storage the billing team uses to share spreadsheets is not thorough. OCR’s guidance specifically requires that the analysis address all ePHI regardless of the electronic medium.

The Analysis Is Out of Date

An analysis performed when the practice moved into its current office, before it added telehealth, before it switched EHR platforms, and before staff began working remotely describes a different practice. Outdated assessments are a recurring theme in OCR resolution agreements.

Risks Were Identified and Never Addressed

Some practices produce a thorough analysis and then file it. When a breach later exploits a vulnerability the practice had already documented, the analysis becomes evidence that the practice knew about the risk and did not act. OCR has described stagnant remediation as a distinct failure.

Business Associates Were Ignored

The practice’s ePHI does not stop at the practice’s walls. Billing companies, transcription services, IT contractors, cloud hosts, and clearinghouses all handle it. The risk analysis should account for the risks those relationships introduce, and the practice should have business associate agreements in place. Our guidance on responding to breach notifications from third party clearinghouses shows how quickly a vendor’s incident becomes the practice’s problem.

Nothing Was Documented

The Security Rule requires documentation. An analysis that existed only as a conversation with an IT contractor does not exist for compliance purposes.

Why a Vendor Questionnaire Is Not a Risk Analysis

Software vendors and compliance platforms market inexpensive, self guided “HIPAA risk assessments” that a practice manager can complete in an afternoon. Some are useful starting points. Many fall short of what OCR expects for four reasons.

They assume a generic practice. Questions are written for an imaginary practice, so they cannot capture the specific systems, workflows, and vulnerabilities of a real one.
They measure policy, not exposure. A question asking whether the practice has an encryption policy says nothing about whether the laptop in the billing office is actually encrypted.
They skip the risk rating. The defining feature of a risk analysis is determining the likelihood and impact of each threat and vulnerability combination. Many questionnaires never perform that step.
They rely on self reporting. The person answering the questions is often the person responsible for the safeguards, and the answers are rarely verified against configurations, logs, or physical inspection.

A defensible analysis can use a questionnaire as one input. It cannot be only a questionnaire.

What OCR Expects: The Nine Elements of a Compliant Risk Analysis

OCR has never mandated a specific methodology, but its Guidance on Risk Analysis Requirements under the HIPAA Security Rule identifies the elements every analysis should include, drawing on NIST Special Publication 800-30. These elements are what OCR investigators look for.

Element	What OCR Expects
1. Scope of the analysis	All ePHI the practice creates, receives, maintains, or transmits, in every location and on every medium
2. Data collection	Identification of where ePHI is stored, received, maintained, or transmitted, documented through inventories, interviews, and review of past projects
3. Threats and vulnerabilities	Reasonably anticipated threats, and vulnerabilities that could be triggered or exploited, documented
4. Current security measures	Assessment and documentation of the safeguards in place and whether they are configured and used properly
5. Likelihood of threat occurrence	An assessment of the probability that each threat will trigger or exploit a specific vulnerability
6. Potential impact	An assessment of the magnitude of harm if each threat occurs
7. Level of risk	Assignment of a risk level for each threat and vulnerability combination, based on likelihood and impact
8. Documentation	A written record of the analysis, its methods, and its findings
9. Periodic review and updates	An ongoing process, revisited as the environment changes

The sections below translate each element into practical steps for a physician or dental practice.

Step by Step: Conducting the Security Risk Analysis

Step 1: Define the Scope

List every location where ePHI exists. That includes each office, any administrative or billing location, staff homes where remote work occurs, and every cloud service. Then list every system type: EHR and practice management system, patient portal, email, fax, phone and voicemail systems, imaging and diagnostic devices, backup systems, file shares, mobile devices, removable media, and any artificial intelligence tools such as ambient scribes that process patient information.

Step 2: Build an Asset and Data Flow Inventory

For each system, document what ePHI it holds, who has access, where the data is stored, how it moves, and who the vendor is. A simple inventory might look like this:

Asset	ePHI Involved	Location	Access	Vendor and BAA Status
Cloud EHR and practice management system	Full clinical and billing records	Vendor hosted	All clinical and billing staff	Vendor; BAA on file
Front desk workstations (4)	Schedules, demographics, insurance	Main office	Front desk staff	Practice owned
Billing manager laptop	Claims exports, aging reports	Office and employee home	Billing manager	Practice owned
Digital x-ray system	Images and patient identifiers	Imaging room	Clinical staff	Equipment vendor; BAA needed for service access
Email system	Referral letters, lab results	Cloud	All staff	Email provider; BAA on file
Network attached backup device	Nightly EHR export	Server closet	IT contractor	IT contractor; BAA on file
Practice cell phones (3)	Texts, call logs	Mobile	Providers	Carrier; no BAA

Then map how data flows. Referral letters arrive by fax and are scanned into the EHR. Lab results arrive through an interface. Claims leave through a clearinghouse. Each handoff is a point where data can be exposed.

Step 3: Identify Threats and Vulnerabilities

A threat is something that could cause harm. A vulnerability is a weakness a threat could exploit. Risk exists only where a threat and a vulnerability meet. Consider threats in four categories:

Human, intentional: phishing, ransomware, credential theft, insider snooping, theft of devices.
Human, unintentional: misdirected email or fax, accidental deletion, lost devices, misconfiguration.
Technical: hardware failure, software defects, unpatched systems, vendor outages.
Environmental: fire, flood, power failure, severe weather.

Then identify the vulnerabilities each threat could exploit: unencrypted laptops, shared logins, missing multifactor authentication, end of life operating systems, unpatched imaging workstations, untested backups, an unlocked server closet, or a former employee whose account was never disabled.

Step 4: Evaluate Current Security Measures

For each risk, document the safeguards already in place and, critically, whether they are working. This is where verification matters. Confirm that encryption is actually enabled. Confirm that backups actually restore. Confirm that terminated users actually lost access. Our article on understanding HIPAA encryption requirements explains why encryption deserves particular attention: it is technically addressable rather than required, but a practice that chooses not to encrypt must document why and adopt an equivalent alternative.

Step 5: Determine Likelihood

Rate how likely each threat is to exploit each vulnerability, given current safeguards. A three or five level scale is common. Base the rating on evidence: the practice’s own incident history, industry breach trends, and the strength of existing controls.

Step 6: Determine Impact

Rate how severe the harm would be if the threat occurred. Consider the volume and sensitivity of records involved, the effect on patient care if systems were unavailable, the financial cost of breach response and notification, and regulatory and reputational consequences.

Step 7: Assign a Risk Level

Combine likelihood and impact to assign a risk level. A simple matrix works for most practices:

Likelihood / Impact	Low Impact	Medium Impact	High Impact
High likelihood	Medium	High	High
Medium likelihood	Low	Medium	High
Low likelihood	Low	Low	Medium

Record the results in a risk register. Each entry should name the asset, the threat, the vulnerability, current controls, likelihood, impact, and the resulting risk level.

Asset	Threat	Vulnerability	Current Controls	Likelihood	Impact	Risk
Billing manager laptop	Theft or loss	Full disk encryption not enabled	Password login	Medium	High	High
All workstations	Phishing leading to ransomware	No multifactor authentication on email	Spam filter, annual training	High	High	High
Network backup device	Ransomware encrypts backups	Backup on same network, never restore tested	Nightly backup	Medium	High	High
Digital x-ray workstation	Malware	Unsupported operating system	Network segmentation absent	Medium	Medium	Medium
Server closet	Unauthorized physical access	Door unlocked during business hours	Located in staff area	Low	Medium	Low

Step 8: Document Everything

The final report should describe the scope, the methodology, the inventory, the threats and vulnerabilities identified, the risk ratings, and the date of the analysis. It should be signed or approved by the security official and retained as required by 45 CFR 164.316, which requires documentation to be retained for six years from the date of creation or the date it was last in effect, whichever is later.

Step 9: Schedule the Review

Set a date for the next review and define the events that will trigger an earlier one. The analysis is a living process, not a one time project.

From Analysis to Risk Management

The risk register is the starting point for the risk management plan required by 45 CFR 164.308(a)(1)(ii)(B). For each risk rated medium or high, the plan should name:

The specific remediation action (for example, enable full disk encryption on all practice laptops)
The person responsible
The target completion date
The resources required
How completion will be verified
The residual risk after remediation

High risks should be addressed first. Some risks may be accepted, but acceptance must be a documented, reasoned decision by leadership, not an omission. Track progress at each compliance committee meeting. If your practice does not yet have a functioning committee, our guide to building an effective healthcare compliance committee explains how to structure one.

The Security Rule’s risk management standard also connects to two related requirements that OCR frequently reviews alongside it: a sanction policy for workforce members who violate security policies, and regular review of information system activity such as audit logs, access reports, and security incident tracking.

How Often Must the Security Risk Analysis Be Updated?

The current Security Rule does not set a fixed interval. It requires the analysis to be reviewed and updated periodically and as needed in response to environmental or operational changes. In practice, three forces point to an annual cycle.

MIPS requires it. The Promoting Interoperability measure requires an analysis conducted or reviewed for each performance year.
OCR expects currency. An analysis that does not reflect current systems will not be accepted as accurate.
The proposed Security Rule would mandate it. The pending rule would require recurring, documented reviews.

Beyond the annual review, update the analysis whenever any of the following occur:

Implementation of a new EHR, practice management system, or major software upgrade
A move, expansion, or new location
A security incident or breach
Adoption of telehealth, remote work, or new mobile devices
Introduction of AI tools that process patient information
A merger, acquisition, or new affiliation
A change in key vendors or business associates

The Security Risk Analysis and MIPS Promoting Interoperability

For MIPS eligible clinicians reporting the Promoting Interoperability category, the 2026 Security Risk Analysis measure requires clinicians to attest that they conducted or reviewed a security risk analysis in accordance with 45 CFR 164.308(a)(1)(ii)(A), and that they implemented security measures to reduce identified risks to a reasonable and appropriate level as part of the risk management process. The analysis must address the security of data created or maintained by certified EHR technology, including encryption.

Several details trip practices up:

Timing. The analysis may be conducted or reviewed outside the performance period, but it must be unique to each performance period and its scope must cover the full performance period.
The measure is required but unscored. Completing it earns no points. Failing to complete it results in a score of zero for the entire Promoting Interoperability category.
Attestation must be supported. Attesting “yes” without a documented analysis creates audit exposure. CMS can request supporting documentation through its data validation and audit process, and an attestation that cannot be supported puts the category score at risk.

A practice that clicked through its attestation without a current, documented analysis has two problems: a MIPS exposure and a HIPAA exposure.

What the Proposed HIPAA Security Rule Update Would Change

In January 2025, HHS published a proposed rule that would substantially overhaul the Security Rule. As of fall 2026, the proposal remained unfinalized, with HHS’s finalization target reported to have slipped to approximately July 2027 and with a large coalition of provider organizations asking HHS to withdraw it. If finalized as proposed, compliance would generally be required 240 days after publication.

The proposal matters for risk analysis because it would convert much of today’s flexible guidance into explicit requirements. Among the proposed changes:

A written technology asset inventory and network map, reviewed and updated at least annually
More detailed required contents for the written risk analysis
Elimination of the distinction between required and addressable implementation specifications
Vulnerability scanning at least every six months and penetration testing at least annually
Defined timelines for patching critical and high risk vulnerabilities
Multifactor authentication and encryption of ePHI at rest and in transit, with limited exceptions
Annual compliance audits and written verification of business associate safeguards

The proposal is not law, and its final form may differ. But a practice that builds its risk analysis today around a documented asset inventory, a data flow map, a verified review of safeguards, and an annual cycle will be well positioned whatever the final rule requires.

Recognized Security Practices: Why Good Security Can Reduce Penalties

A 2021 amendment to the HITECH Act (Public Law 116-321) requires HHS to consider whether a covered entity or business associate had recognized security practices in place for the previous 12 months when determining fines and the terms of audits or resolution agreements. Recognized security practices include the NIST Cybersecurity Framework and the Health Industry Cybersecurity Practices published through the HHS 405(d) program.

This creates a meaningful incentive. A practice that can document that it adopted and followed a recognized framework, and that its risk analysis was used to prioritize those practices, is in a materially better position if a breach occurs.

Tools and Frameworks for the Security Risk Analysis

Several free government resources can support the process:

The HHS Security Risk Assessment Tool. Developed by HHS and the Assistant Secretary for Technology Policy, the SRA Tool walks small and medium practices through a structured questionnaire and produces a report. It is a useful framework. It is not a finished analysis, and using it does not by itself guarantee compliance. The quality of the result depends entirely on the accuracy and completeness of the inputs.
NIST SP 800-66 Revision 2. Implementing the HIPAA Security Rule: A Cybersecurity Resource Guide maps each Security Rule standard to practical activities and includes a detailed risk assessment approach.
NIST SP 800-30. The Guide for Conducting Risk Assessments is the methodology on which OCR’s guidance draws.
Health Industry Cybersecurity Practices. The 405(d) HICP publication offers prioritized practices scaled for small, medium, and large organizations.

Downloadable “HIPAA risk analysis templates” can also help organize the work. The test for any template is whether, once completed, it contains a practice specific inventory, documented threats and vulnerabilities, likelihood and impact ratings, assigned risk levels, and a remediation plan. If it does not, it is a checklist.

Special Considerations for Small Medical and Dental Practices

Small practices face the same requirement with fewer resources, and DoctorsManagement has written about why the SRA remains a major burden for small practices. A few areas deserve particular attention:

Cloud EHRs do not transfer the obligation. A cloud hosted EHR reduces some on premises risks but introduces others, such as account takeover and dependence on internet connectivity. The practice still owns its risk analysis.
Imaging and diagnostic equipment. X-ray, ultrasound, and other devices often run outdated operating systems and are rarely patched. Dental practices are especially exposed here.
Remote and personal devices. Billing staff working from home and providers reviewing charts on personal phones extend the practice’s environment into places it does not control.
Email and fax. Misdirected communications remain one of the most common sources of small breaches.
Artificial intelligence tools. Ambient scribes, chatbots, and AI enabled documentation tools process ePHI and require both a business associate agreement and inclusion in the analysis. See AI in Healthcare: Innovation Is Here, But So Are New Risks.
Physical security. Small offices often have server equipment in unlocked closets and workstations visible from the waiting room.

If OCR Asks for Your Risk Analysis

OCR contact usually arrives as a data request letter following a breach report or a patient complaint. The letter typically sets a short response deadline and asks for the risk analysis and risk management plan in effect before the incident, along with related policies and evidence. How a practice responds in those first weeks shapes the rest of the investigation.

Do not create a backdated analysis. Producing a document dated before the incident that was actually written after it turns a compliance deficiency into a credibility problem, and potentially something worse.
Produce what exists, accurately described. If the most recent analysis is outdated or incomplete, say so, and describe the steps already underway to correct it.
Start a current analysis immediately. OCR considers corrective action taken after a problem is discovered. A thorough, current analysis completed promptly demonstrates good faith.
Gather evidence of recognized security practices. Documentation that the practice followed a recognized framework over the prior 12 months can affect the outcome, as described above.
Coordinate with counsel. For investigations involving a significant breach, involve healthcare counsel early. DoctorsManagement supports practices and their attorneys by producing the analytical and compliance record; legal strategy belongs with counsel.

A practice that already maintains a current, documented analysis rarely faces this scramble. That is the strongest argument for doing the work before anyone asks.

When to Bring in an Outside Assessor

Many practices can conduct a reasonable analysis internally. An independent assessor adds the most value when:

The practice has never performed a documented analysis
The last analysis is more than a year old or predates major system changes
No one on staff has security assessment experience
The person responsible for IT would be assessing their own work
The practice has experienced a breach or received an OCR inquiry
The practice is preparing for a sale, merger, or payer audit

An outside assessor brings objectivity, verifies rather than accepts self reported answers, and produces documentation built for scrutiny. Our earlier guidance on strengthening HIPAA policies and conducting a security risk analysis covers how the analysis and the policy framework fit together.

How DoctorsManagement Helps

DoctorsManagement’s HIPAA Security Risk Analysis is a project based engagement for medical and dental practices, with no ongoing service contract required. It follows a five phase process:

Kickoff and planning. Define objectives, scope, roles, and timelines.
Detailed risk assessment. Evaluate policies, procedures, and administrative, physical, and technical safeguards.
Risk identification and deficiency report. Document vulnerabilities and compliance gaps.
Executive summary and final report. Prioritize mitigation steps for leadership and audit readiness.
One on one consultation. Review results and plan future security initiatives.

The engagement produces a documented SRA, a deficiency report, an executive summary, and a mitigation roadmap. Practices that need ongoing support can pair it with DoctorsManagement’s broader HIPAA Compliance services, including policies, manuals, and workforce training, or with a full Practice Assessment.

If your practice cannot produce a current, documented risk analysis today, schedule a discovery call with our compliance team.

Frequently Asked Questions

Is a HIPAA security risk analysis required for small practices?

Yes. The requirement applies to every covered entity and business associate regardless of size. The Security Rule allows a small practice to scale the analysis to its size and complexity, but not to skip it.

What is the difference between a security risk analysis and a security risk assessment?

In everyday use, the terms are interchangeable. The regulation uses “risk analysis,” and the HHS tool uses “security risk assessment.” Both refer to identifying threats and vulnerabilities to ePHI and rating the resulting risk.

How often should a medical practice update its security risk analysis?

The current rule requires periodic review and updates when the environment changes. For practical purposes, review it at least annually, which also satisfies the MIPS requirement, and update it whenever the practice adopts new systems, moves, experiences an incident, or changes key vendors.

Does my EHR vendor’s risk analysis cover my practice?

No. A vendor’s analysis covers the vendor’s own systems and obligations as a business associate. The practice must analyze its own environment, including how it accesses and uses the EHR and every other system that holds ePHI.

Can I use the HHS SRA Tool to meet the requirement?

The tool can help structure the analysis, but completing it does not by itself guarantee compliance. The results are only as accurate as the inputs, and the practice must still verify safeguards, document risk ratings, and implement a risk management plan.

What does OCR request during an investigation?

OCR commonly requests the current risk analysis and prior versions, the risk management plan and evidence of remediation, security policies and procedures, training records, business associate agreements, and documentation of the specific safeguards relevant to the incident under investigation.

What happens if we attest to the MIPS security risk analysis measure without completing one?

Failing to complete the measure results in a zero for the Promoting Interoperability category. Attesting without a documented analysis also creates audit exposure, because CMS can request supporting documentation.

Is a HIPAA risk analysis template enough?

Only if the completed template includes a practice specific asset inventory, documented threats and vulnerabilities, likelihood and impact ratings, assigned risk levels, and a remediation plan. A template that records only yes or no answers about policies is a checklist, not an analysis.

How long must we keep our security risk analysis?

HIPAA requires Security Rule documentation to be retained for six years from the date of creation or the date it was last in effect, whichever is later. Keep every version, since prior analyses show OCR how the practice’s security program evolved.

References

U.S. Department of Health and Human Services: Guidance on Risk Analysis Requirements under the HIPAA Security Rule
Electronic Code of Federal Regulations: 45 CFR 164.308, Administrative Safeguards
National Institute of Standards and Technology: SP 800-66 Revision 2 and SP 800-30 Revision 1
HealthIT.gov: Security Risk Assessment Tool
HHS 405(d) Program: Health Industry Cybersecurity Practices
Nixon Peabody: OCR’s 14th Risk Analysis Initiative enforcement action
National Law Review: OCR Risk Analysis Enforcement Initiative continues
HIPAA Journal: HIPAA Violation Cases
Pact One: Is the HIPAA Security Rule Final in 2026?

The post HIPAA Security Risk Analysis: What OCR Expects and Why Most Practices Fail the Audit appeared first on DoctorsManagement.

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