Security incident procedures

To meet the HIPAA security incident procedures requirement, you must maintain written, operational procedures to identify security incidents affecting ePHI, respond to them, and document what happened and what you did. Build a repeatable incident lifecycle (detect → triage → contain → eradicate → recover → close) and retain incident records that prove the process runs. ¹

Key takeaways:

• Your obligation is procedural and evidentiary: identify, respond, and document security incidents involving ePHI. ¹
• “Document” means audit-ready incident records, not just a policy on a shared drive.
• Operationalize with clear roles, severity tiers, runbooks, and a single system of record for incident tickets and closure notes.

The security incident procedures requirement is one of the fastest ways for HIPAA programs to fail an audit: teams can often describe how they “would respond,” but cannot produce consistent incident records that show how they actually respond. HIPAA expects you to maintain procedures that reliably identify security incidents that affect electronic protected health information (ePHI), respond in a timely and consistent way, and document the incident and your actions. ¹

For a Compliance Officer, CCO, or GRC lead, the practical goal is simple: create a workflow that (1) captures suspected incidents from multiple intake channels, (2) routes them to accountable owners, (3) drives containment and recovery with approved playbooks, and (4) produces a complete record that stands on its own during an OCR inquiry, customer audit, or internal review. Your incident procedures also need to work across third parties that touch ePHI, because many incidents originate in outsourced infrastructure, managed services, EHR platforms, billing partners, and cloud tooling.

This page gives requirement-level implementation guidance you can execute quickly: who owns what, what artifacts to produce, what auditors ask for, and how to prove the control operates.

Regulatory text

Requirement (excerpt): “Maintain procedures to identify, respond to, and document security incidents affecting ePHI.” ¹

Operator interpretation (what this means in practice)

You must have documented procedures that are actually used to:

1. Identify security incidents that could affect ePHI (alerts, reports, anomalies, user complaints, third-party notifications).
2. Respond in a controlled, repeatable way (triage, containment, investigation, remediation, recovery, escalation).
3. Document both the incident and your response (timeline, scope, decisions, evidence, and closure rationale). ¹

This requirement is not limited to “confirmed breaches.” It covers suspected and confirmed security incidents that affect ePHI systems, users, or data flows. Your procedures should also make it easy to answer: What happened, what was the impact to ePHI, what did you do, and how do you know it’s fixed?

Plain-English requirement summary

Maintain a working incident response process for ePHI systems. Write it down, train people on it, run it, and keep records that prove you detected, handled, and closed incidents in a consistent manner. ¹

Who it applies to (entity and operational context)

In scope entities

• HIPAA Covered Entities (providers, health plans, clearinghouses). ¹
• HIPAA Business Associates that create, receive, maintain, or transmit ePHI. ¹

In scope operations

• Any workforce member or system that stores, processes, or transmits ePHI (EHR, billing, imaging, patient portals, data warehouses, endpoint devices).
• Security operations (SOC), IT operations, cloud operations, and application engineering.
• Third parties with access to your ePHI environment (MSPs, hosting providers, SaaS platforms, claims/billing services). Your procedures must define how third-party incidents are received, tracked, and escalated internally.

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

The fastest path is to build a minimal but complete incident lifecycle and make one system of record non-negotiable.

Step 1: Define what counts as a “security incident” for your environment

• Write a practical definition that includes: unauthorized access, malware, ransomware indicators, lost devices, credential compromise, misconfiguration exposing ePHI, suspicious admin activity, and third-party notifications involving ePHI systems.
• Include “suspected incident” handling so staff do not wait for certainty before reporting.

Deliverable: Security Incident Procedures document, with definitions and examples. ¹

Step 2: Establish intake channels and a single tracking system

• Intake channels: security tooling alerts, IT ticketing, a dedicated email alias, hotline/Teams channel, and third-party notification path.
• Choose one system of record (ticketing/IR platform) where every incident gets a unique identifier and lifecycle states.

Deliverables: Intake workflow, triage queue, incident ticket template.

Step 3: Create a severity model and escalation rules tied to ePHI

Build severity tiers that explicitly consider:

• Whether ePHI systems/data stores are involved.
• Whether privileged accounts are implicated.
• Whether there is ongoing active threat activity.

Define required escalations:

• Security/IT on-call
• Privacy Officer (or privacy function)
• Legal (as appropriate)
• Executive notification thresholds
• Third-party coordination triggers

Deliverables: Severity matrix; escalation contact list; on-call procedure.

Step 4: Assign roles with decision rights (RACI)

Minimum roles to document:

• Incident Commander (runs the process and timeline)
• Security lead (investigation, containment)
• IT/app owner (system recovery, configuration fixes)
• Privacy lead (ePHI impact assessment inputs)
• Comms lead (internal/external messaging control)
• Third-party manager (coordinates vendor/MSP actions)

Keep decision rights explicit: who can isolate hosts, disable accounts, approve emergency changes, and declare closure.

Deliverables: IR RACI; delegated authorities; emergency change procedure linkage.

Step 5: Publish core runbooks (playbooks) for common ePHI-impacting incidents

Start with the incidents you can predict:

• Lost/stolen endpoint with ePHI access
• Phishing leading to credential compromise
• Ransomware suspicion in an ePHI network segment
• Misconfiguration exposing storage or logs containing ePHI
• Third-party notification involving ePHI environment

Each runbook should include: immediate containment actions, evidence to preserve, systems to check, and criteria to escalate to privacy/legal.

Deliverables: Runbooks; evidence preservation checklist.

Step 6: Build documentation requirements into the workflow (don’t rely on memory)

For every incident ticket, require fields for:

• Detection source and timestamp
• Systems/users involved
• ePHI touchpoints (apps, databases, file shares)
• Containment actions and timestamps
• Investigation summary and evidence references
• Root cause and corrective actions
• Closure approval and lessons learned

Deliverables: Incident ticket template; closure checklist; post-incident review template.
This directly supports “document security incidents affecting ePHI.” ¹

Step 7: Train and test the procedures

• Train frontline staff on “report fast, don’t self-investigate.”
• Tabletop at least your highest-risk scenario for ePHI systems (for example, ransomware suspicion).
• After any exercise or real incident, update runbooks and contact lists.

Deliverables: Training roster; tabletop agenda; after-action notes; procedure revision history.

Step 8: Prove it operates (continuous control operation)

Your evidence should show:

• Incidents are logged consistently.
• Responses follow a defined lifecycle.
• Closure is documented and approved.
• Corrective actions are tracked to completion.

How Daydream fits naturally: Many teams struggle to make evidence collection routine. Daydream can serve as a control hub to map your incident procedure to HIPAA expectations, request/collect incident records for audits, and track remediation tasks so you can show operation rather than intent.

Required evidence and artifacts to retain

Keep artifacts in a way you can export quickly for an audit or investigation.

Policy/procedure artifacts

• Security Incident Procedures document (current version + revision history). ¹
• Severity matrix and escalation rules.
• IR roles/RACI and contact lists.
• Runbooks for top incident types.

Operational evidence (most important)

• Incident register/list (even if most are low severity).
• Individual incident tickets with timestamps, actions taken, and closure notes. ¹
• Evidence references: SIEM alerts, EDR detections, firewall logs, IAM logs, cloud audit logs (store links/hashes, not necessarily raw logs in the ticket).
• Post-incident review notes and corrective action tracking.
• Training completion records and tabletop artifacts.

Third-party artifacts

• Third-party incident notification emails/tickets.
• Coordination notes and responsibility split (what they did vs. what you did).
• Any contract/BAA language cross-reference used to drive notification and cooperation (store a pointer, not the whole contract, if contracts are controlled elsewhere).

Common exam/audit questions and hangups

Auditors and regulators tend to probe for “operating effectiveness” signals:

1. Show me your incident procedures and the last time you updated them.
   Hangup: no revision history or the document is generic and not environment-specific.

2. Provide a list of security incidents for a recent period and the supporting tickets.
   Hangup: teams only track “major” incidents; small but relevant events are missing.

3. How do you know incidents affecting ePHI are identified?
   Hangup: no link between monitoring coverage and ePHI systems; no defined intake from third parties.

4. Walk through one incident end-to-end with evidence.
   Hangup: containment steps exist, but investigation and closure rationale are not documented.

5. How are corrective actions tracked and verified?
   Hangup: lessons learned exist, but remediation is not assigned, dated, and closed.

Frequent implementation mistakes and how to avoid them

Mistake	Why it fails	Fix
Policy exists, tickets don’t	You can’t prove you “maintain procedures” operationally. 1	Require every suspected incident to be logged in one system.
No ePHI impact prompt	Teams forget to assess whether affected systems handle ePHI.	Add mandatory “ePHI touchpoint” fields and escalation triggers.
Third-party incidents handled informally	Emails get lost and timelines are unclear.	Create a third-party intake path and open an internal incident ticket for every notification.
Evidence scattered across tools	You can’t reconstruct what happened quickly.	Store links, case IDs, and exported artifacts in the incident record.
Closure = “looks fine now”	Auditors want root cause and corrective actions.	Use a closure checklist that requires root cause + remediation tasks.

Enforcement context and risk implications (practical)

No public enforcement case sources were provided in your source catalog for this requirement, so this page does not cite specific cases. Practically, weak incident procedures increase the chance that an ePHI-impacting event becomes harder to contain, harder to investigate, and harder to explain to regulators, customers, and partners. Documentation gaps are also credibility gaps; they slow response and make oversight questions difficult to answer with evidence. ¹

Practical 30/60/90-day execution plan

First 30 days: get to “documented and usable”

• Name an incident owner (Incident Commander function) and backups.
• Publish the Security Incident Procedures document with definition, lifecycle, and roles. ¹
• Stand up the single system of record (ticket template + required fields).
• Build severity tiers and escalation contacts, including privacy and third-party escalation.

Exit criteria: You can open, route, and close an incident ticket with required documentation.

Days 31–60: make it operational for ePHI and third parties

• Inventory your top ePHI systems and tag them in monitoring and ticket workflows.
• Write runbooks for the top incident scenarios affecting those systems.
• Implement third-party incident intake and internal tracking rules.
• Run one tabletop focused on an ePHI system scenario; update procedures based on findings.

Exit criteria: You can demonstrate detection-to-closure on a realistic scenario with artifacts.

Days 61–90: prove operating effectiveness and tighten evidence

• Review recent incidents and fill documentation gaps (timeline, root cause, closure approval).
• Add a monthly incident review meeting with metrics that do not require statistics (trend notes, recurring causes, overdue corrective actions).
• Confirm logs/evidence sources are accessible and retained long enough to support investigations (document where they live and who can export them).
• Use Daydream to centralize evidence requests, map artifacts to the security incident procedures requirement, and keep an audit-ready package current.

Exit criteria: You can answer an auditor request quickly: procedures + incident register + complete sample cases.

Frequently Asked Questions

What qualifies as a “security incident” under the security incident procedures requirement?

Treat any suspected or confirmed event that could compromise the confidentiality, integrity, or availability of systems containing ePHI as an incident to be identified, responded to, and documented. Your procedures should explicitly list common examples so staff can report quickly. ¹

Do we have to document minor incidents that don’t end up involving ePHI?

Document suspected incidents through triage and record the determination and rationale. That record shows you can identify and respond consistently, even when you later scope out ePHI impact. ¹

Can our IT ticketing system count as incident documentation?

Yes, if the ticket fields and workflow capture the required incident lifecycle details: identification source, response actions, evidence references, and closure notes. If your tickets only say “fixed,” you will struggle to prove compliance. ¹

How should we handle incidents reported by a third party that hosts or processes ePHI?

Open an internal incident record for every third-party notification, track what they report, document your internal assessment and decisions, and capture communications and closure criteria. Your obligation is to maintain procedures and documentation on your side as well. ¹

Who should own incident closure: Security, IT, or Compliance?

Security or IT usually owns technical closure, but your procedure should require confirmation that ePHI impact was assessed and that corrective actions are assigned. Many organizations use a shared closure approval between the Incident Commander and the system owner, with privacy/compliance sign-off for ePHI-relevant cases. ¹

What evidence is most persuasive in an audit?

Complete incident records with timestamps, actions taken, and closure rationale, backed by references to logs/alerts and corrective action tickets. A clean incident register plus a few well-documented cases typically outperforms a long policy with no operational proof. 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 lifecycle management

Footnotes

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