Policies and documentation

To meet the HIPAA policies and documentation requirement, you must keep your HIPAA policies and procedures current, approved, version-controlled, and backed by retained documentation that proves they were followed. Operationalize this by establishing a formal policy lifecycle (ownership, review cadence, approvals, distribution) and a documentation retention system that is easy to produce during an OCR inquiry. ¹

Key takeaways:

• “Current” means reviewed, updated after material changes, and aligned to your actual environment, not a stale template. ¹
• Auditors and OCR look for proof of operation: approvals, training/acknowledgements, exception handling, and retained records. ¹
• Versioning plus periodic review cycles is the fastest path to audit-ready evidence for the policies and documentation requirement. ¹

The HIPAA policies and documentation requirement is deceptively simple: maintain current HIPAA policies, procedures, and retained documentation. In practice, this requirement is where many programs fail because “having policies” is not the same as having policies that match operations, are approved by accountable leaders, and are supported by records that show consistent execution. ¹

For a CCO, Compliance Officer, or GRC lead, the goal is speed and defensibility. You need a system that (1) keeps required HIPAA content accurate as your environment changes, (2) assigns clear owners for each policy/procedure, and (3) produces evidence on demand with minimal scrambling. That evidence has to tell a coherent story: what the organization decided, when it decided it, who approved it, how it was communicated, and what records exist to prove the procedure actually ran. ¹

This page gives requirement-level implementation guidance focused on operational steps, artifacts, and exam-ready responses. It avoids legal speculation and sticks to what you can implement and defend under the HIPAA Security Rule source provided. ¹

Regulatory text

Regulatory excerpt (provided): “Maintain current HIPAA policies, procedures, and retained documentation.” ¹

Operator interpretation (what you must do):

• Maintain a complete, accessible set of HIPAA security policies and procedures that reflect how you protect ePHI in your real environment. ¹
• Keep them “current” by running a formal review and update process, with documented approvals and effective dates. ¹
• Retain documentation (records, logs, approvals, evidence) that demonstrates those policies and procedures were implemented and followed. ¹

Plain-English requirement interpretation (what “passes”)

You pass the policies and documentation requirement when you can quickly produce:

1. the latest approved version of each relevant HIPAA policy/procedure, and
2. the retained records that show the policy/procedure operated (or that exceptions were managed under a defined process). ¹

A practical way to think about it: policies say “we will,” procedures say “how we do,” documentation proves “we did.” Keep all three aligned.

Who it applies to

Entity scope: Covered Entities and Business Associates that create, receive, maintain, or transmit electronic protected health information (ePHI). ¹

Operational contexts where this becomes urgent:

• You rely on third parties for hosting, EHR/EMR, billing, call centers, IT support, or managed security services where ePHI touches external systems.
• You have frequent change (new applications, cloud migrations, M&A, new sites, remote workforce).
• You run incident response, access reviews, audit logging, device management, or workforce onboarding/offboarding processes tied to ePHI access. ¹

What you actually need to do (step-by-step)

Step 1: Build a HIPAA policy/procedure inventory

Create a register with, at minimum:

• Policy/procedure name
• Scope (systems, teams, locations)
• Owner (person, not a committee)
• Approver (role with authority)
• Current version and effective date
• Next review date
• Where evidence is stored (link to repository)
• Related standards/processes (e.g., incident response, access management) ¹

Execution tip: If you use Daydream, treat this as your control library index: each item maps to an owner, a workflow, and evidence requests.

Step 2: Standardize document control (versioning + approvals)

Implement a minimum document control standard:

• Unique document IDs
• Version history (what changed, when, why)
• Approval workflow (prepared by, reviewed by, approved by)
• Effective date and retirement date (if replaced)
• Distribution method (how the workforce finds the current version)
• “Uncontrolled if printed” marking for PDFs if you allow downloads

Recommended control: Version policies and document periodic policy review cycles. ¹

Step 3: Define what “current” means for your environment

Write and adopt a policy lifecycle rule you can defend, such as:

• Review policies on a scheduled cadence and also upon material change (new system handling ePHI, major org change, security incident, or third-party change impacting ePHI).
• Document the trigger and resulting update, even if the update is “no change.” ¹

Avoid promising a cadence you cannot execute. Examiners will punish missed commitments more than a realistic plan.

Step 4: Map each policy to operational procedures and evidence

For each policy, identify:

• The procedures that implement it (runbooks, SOPs, tickets, playbooks)
• The systems of record that generate evidence (IAM platform, ticketing system, SIEM logs, training platform, HRIS)
• The evidence you will retain and who is responsible for retention ¹

Example (what “mapped” looks like):

• Access control policy → procedure: joiner/mover/leaver workflow → evidence: access requests, approvals, deprovision tickets, periodic access review outputs.

Step 5: Implement a documentation retention and retrieval process

Create a retention schedule and a retrieval method:

• Retention schedule: define how long HIPAA-related records are kept and where. Keep it consistent across departments.
• Retrieval: define who can pull evidence, how quickly, and how you preserve integrity (read-only exports, audit trails).

Even without a numeric retention period stated in the provided excerpt, your program needs a consistent rule and the ability to produce what you retained. ¹

Step 6: Operationalize exceptions and compensating controls

Reality will break your procedures. Add an exception process:

• Define when exceptions are allowed
• Require documented risk acceptance and compensating controls
• Set an expiration date and track closure ¹

This prevents “shadow process” drift where teams bypass the written procedure and you cannot prove governance.

Step 7: Test evidence production (tabletop for audits)

Run an internal “OCR-ready” drill:

• Pick a policy (e.g., incident response)
• Produce the current approved document
• Produce evidence for a recent incident or test
• Show approvals, communications, and post-incident actions

If it takes days and multiple people, fix the repository structure and ownership model. ¹

Required evidence and artifacts to retain

Use this as a checklist for the policies and documentation requirement:

Policy/procedure governance artifacts

• Policy and procedure inventory/register
• Current approved versions (with effective dates)
• Version history and change logs
• Review records (including “no change” attestations)
• Approval records (named approver, date/time)
• Distribution records (intranet publication record, email notice, policy portal logs)

Operational evidence (proof the procedure ran)

• Training assignments and completions for HIPAA-required topics tied to the policies
• Workforce acknowledgements of key policies (acceptable use, access control, incident reporting)
• Tickets/records from access provisioning and deprovisioning
• Security incident records and post-incident documentation
• Third-party due diligence records where ePHI is involved (questionnaires, security addenda, BAAs, risk reviews), stored in a way that is discoverable during an inquiry ¹

Retention and integrity artifacts

• Document retention schedule and storage locations
• Access controls for the policy repository (who can edit, who can approve)
• Audit trails for document changes (SharePoint/Confluence change history or GRC system logs)

Common exam/audit questions and hangups

Expect questions like:

• “Show me your current HIPAA security policies and procedures. Who approved them and when were they last reviewed?” ¹
• “How do you ensure staff are following the procedure, not just reading a policy?”
• “Where is the documentation retained, and can you produce it for a sample set of events?”
• “How do you control versions so staff don’t use outdated procedures?”
• “What triggers an out-of-cycle update?”

Hangups that slow teams down:

• Policies exist, but procedures live in tribal knowledge or Slack.
• Evidence exists, but it is scattered across ticketing, email, and shared drives with no index.
• Approvals are informal (“looks good” in chat) and not captured as a record.

Frequent implementation mistakes and how to avoid them

Mistake	Why it fails	Fix
Copying a HIPAA template and never aligning it to real systems	Examiners test operational reality	Tie each policy to your actual tools, teams, and workflows. 1
No document owner	Reviews never happen	Assign a named owner and backup owner in the inventory.
Versioning without distribution control	Staff use stale copies	Use a single source of truth repository and disable editing outside the workflow.
Retaining “documents” but not operational records	No proof controls ran	Define evidence per procedure and store it with consistent naming and indexing.
No exception process	Teams bypass procedures silently	Require documented exceptions, compensating controls, and expiry tracking. 1

Enforcement context and risk implications

No public enforcement case sources were provided in the supplied catalog, so this page does not cite specific OCR settlements or penalties. The practical risk remains straightforward: if you cannot show current policies and retained documentation, you may be unable to demonstrate compliance during an investigation, breach response, or audit, even if some controls were performed. ¹

Practical 30/60/90-day execution plan

Days 0–30: Get control of the document universe

• Stand up a single system of record for HIPAA policies/procedures (policy portal, GRC tool, or controlled SharePoint).
• Create the policy/procedure inventory with owners, approvers, and storage links.
• Identify the highest-risk policies first (access control, incident response, third-party management where ePHI is shared).
• Implement minimum document control: version history, approvals, effective dates, and a review field. ¹

Days 31–60: Connect policies to evidence

• For each priority policy, document the implementing procedure and the evidence source.
• Build an evidence index: what record, produced by which system, owned by which team, stored where.
• Define and publish the exception process and risk acceptance workflow.
• Run one evidence production drill and record the gaps discovered. ¹

Days 61–90: Make it durable and repeatable

• Complete review/approval cycles for remaining HIPAA policy areas in scope.
• Automate reminders for periodic reviews and exception expirations (GRC workflow, ticketing tasks).
• Establish a standard audit response package for HIPAA documentation requests (policy set + evidence map + sample evidence exports).
• If you use Daydream, configure continuous control monitoring and evidence collection requests so policy reviews and artifacts are tracked in one place. ¹

Frequently Asked Questions

Do we need separate HIPAA policies for Covered Entity vs Business Associate obligations?

You need policies and procedures that reflect your role and how ePHI flows through your environment. If you operate as both in different contexts, document the scope boundaries and make role-specific procedures explicit. ¹

What does “current” mean if our environment changes constantly?

Define “current” with two mechanisms: scheduled reviews and change-triggered reviews (new ePHI system, major third-party change, incident). Record the review outcome even if you decide no update is needed. ¹

Are tickets and system logs acceptable “retained documentation”?

Yes, if they are reliable records of the procedure operating and you can retrieve them. Preserve integrity with access controls and audit trails, and index them so you can produce samples quickly. ¹

How do we handle procedures owned by IT but governed by Compliance?

Put IT as the procedure owner and Compliance as the policy owner or approver, then document the RACI in the inventory. The exam question is accountability: who keeps it current and who attests it matches requirements. ¹

What’s the minimum set of artifacts we should be able to produce on demand?

Current approved policies/procedures, version history, review/approval records, and a small set of operational evidence samples for each priority area (access changes, incidents, training/acknowledgements). If you can’t produce these quickly, fix the repository and indexing first. ¹

We have policies, but staff can’t find them. Is that a compliance issue?

It becomes a practical compliance failure because you cannot show workforce-facing control operation. Centralize publication, retire old copies, and track distribution or acknowledgement for high-impact policies. ¹

Related compliance topics

• 2025 SEC Marketing Rule Examination Focus Areas
• Access and identity controls
• Access Control (AC)
• Access control and identity discipline
• Access control management

Footnotes

1. HIPAA Security Rule (45 CFR Part 164 Subpart C)