Purpose:
Evaluate privacy-related risks to PHI confidentiality, integrity, and availability under §164.308(a)(1).
Instructions:
Conduct annual risk assessments.
Document findings and corrective actions.
Retain reports for six years.
Optional Template:
Purpose:
This template helps organizations evaluate potential risks to the confidentiality, integrity, and availability of Protected Health Information (PHI). Regular assessments ensure proactive identification and mitigation of vulnerabilities, aligning with §164.308(a)(1).
Instructions for Use
Conduct Annually or After Major Changes:
Perform a privacy risk assessment annually or after significant changes to systems or processes affecting PHI.Prioritize Risks:
Use the risk score to prioritize mitigation efforts, focusing on high-impact and high-likelihood risks first.Document Mitigation Efforts:
Record all planned and completed actions in the Mitigation Plan section.Reassess Periodically:
Schedule follow-ups to confirm that mitigation measures remain effective and no new risks have emerged.
Privacy Risk Assessment Template
Field | Description |
Assessment Date | The date the risk assessment is conducted. |
Assessor Name | Name of the individual or team conducting the assessment. |
Risk Category | Area of concern (e.g., access control, data retention, breach notification). |
Identified Risk | Description of the specific risk (e.g., unauthorized access, insufficient training). |
Likelihood of Occurrence | Probability of the risk materializing (e.g., High, Medium, Low). |
Impact Level | Severity of the impact if the risk occurs (e.g., High, Medium, Low). |
Risk Score | Combined likelihood and impact score to prioritize risks. |
Mitigation Plan | Actions proposed to address the identified risk. |
Responsible Party | Person or department responsible for implementing mitigation. |
Follow-Up Date | Date to reassess the risk and verify mitigation effectiveness.
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