Organizations adhere to a rigorous record-keeping practice, meticulously documenting the movements of hardware and electronic media, alongside details of the individuals responsible for these assets. This critical process is indispensable for monitoring the physical whereabouts and secure handling of sensitive equipment, storage media, and electronic devices, including those containing Protected Health Information (PHI). By maintaining detailed records, organizations strengthen security measures, ensure accountability, and demonstrate compliance with regulatory requirements.

The record-keeping protocol encompasses the entire lifecycle of hardware and electronic media, covering movement, transfer, and disposal. Each entry in the record includes vital information such as the asset's description, unique identifier, location, date, time, and the responsible individual. This meticulous documentation is instrumental in monitoring asset usage, detecting potential security breaches, and guaranteeing the proper handling of devices containing sensitive information.

As an additional security measure, organizations ensure the creation of a retrievable, exact copy of electronic protected health information (ePHI) before the movement of equipment, whenever needed. This proactive step involves capturing a complete and accurate duplicate of ePHI to mitigate the risk of data loss or compromise during equipment transitions.

Moreover, organizations establish and implement procedures for obtaining necessary electronic protected health information (ePHI) during an emergency. These procedures are designed to ensure swift and secure access to critical health information in emergency situations, taking into account the unique challenges and priorities during such events. The establishment of clear protocols enables authorized personnel to access ePHI efficiently while maintaining the necessary security measures.

These records serve not only as a security measure but also as a powerful accountability tool, mitigating the risks of unauthorized access, loss, or theft of hardware and media that could compromise the confidentiality and integrity of electronic data.

Priority: High

Category: Emergency Response and Business Continuity

Services Associated with AWS:

AWS Identity and Access Management (IAM)

AWS Key Management Service (KMS)

AWS Security Hub

Services Associated with Azure:

Azure Identity and Access Management

Azure Active Directory

Azure Security Center

Objective Evidence:

- Administrative: Documented policies and procedures for recording hardware and media movements

- Administrative: Supporting documentation demonstrating the proper handling and tracking of electronic media

- Technical: Records and logs of hardware and media movements

- Technical: Documentation of procedures for creating retrievable, exact copies of ePHI before equipment movement

- Technical: Procedures for obtaining necessary ePHI during an emergency

Possible Technology Considerations:

- Emergency Access Systems

- Encryption and Decryption Protocols

- Backup and Recovery Solutions

- Secure Communication Channels

- Identity and Access Management (IAM) Systems

What needs to be answered:

  • Are there documented policies and procedures for recording the movements of hardware and electronic media?
  • Can the organization provide evidence of how these records are maintained and used for accountability?
  • Are there mechanisms in place to capture and document the movements of hardware and electronic media, including the responsible individuals?
  • Is there a documented procedure for creating retrievable, exact copies of ePHI before the movement of equipment?
  • Have procedures been established and implemented for obtaining necessary ePHI during an emergency?

More details: The maintenance of records and the implementation of emergency access procedures are fundamental practices for safeguarding electronic data, especially PHI. These measures help prevent data breaches, unauthorized access, and ensure proper asset and emergency response management throughout the lifecycle of sensitive information.