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 implement physical safeguards for all workstations that access electronic protected health information (ePHI) to restrict access to authorized users. These safeguards include measures such as physical access controls, secure workstation placement, and user authentication mechanisms. The goal is to prevent unauthorized individuals from gaining physical access to workstations, ensuring that only authorized users can interact with systems containing ePHI.

Additionally, organizations implement policies and procedures that specify the proper functions to be performed, the manner in which those functions are to be performed, and the physical attributes of the surroundings of a specific workstation or class of workstation that can access ePHI. These policies are designed to define and enforce the appropriate use of workstations, ensuring that authorized personnel perform only the necessary functions in a manner compliant with security and privacy requirements. The physical attributes of the surroundings are considered to further enhance the security posture of the workstations.

Furthermore, organizations establish policies and procedures to document repairs and modifications to the physical components of a facility related to security. This documentation includes records of repairs or changes made to security-sensitive elements such as hardware, walls, doors, and locks. Keeping detailed records of these modifications is essential for maintaining a comprehensive understanding of the facility's security infrastructure and ensuring that any alterations align with security policies and standards.

In addition to these measures, organizations implement procedures to control and validate a person's access to facilities based on their role or function. This includes robust visitor control processes to monitor and regulate access for individuals who are not regular employees. The access control is tied to the person's role or function within the organization, ensuring that they only have access to the areas and resources necessary for their duties.

Moreover, organizations implement controls for access to software programs used for testing and revision. This includes defining roles and responsibilities for individuals involved in testing and revision processes and implementing access controls to restrict unauthorized access to these critical software programs. These controls help prevent unauthorized modifications, ensure the integrity of testing processes, and maintain the security of software used in the development and revision of systems containing ePHI.

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: Access Control and Facility Security

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: Documentation of physical safeguards implemented for workstations accessing ePHI

- Administrative: Policies and procedures specifying the proper functions, manner, and physical attributes of workstations accessing ePHI

- Administrative: Policies and procedures documenting repairs and modifications to the physical components of the facility related to security

- Administrative: Procedures for controlling and validating a person's access to facilities based on their role or function

- Administrative: Controls for access to software programs used for testing and revision

Possible Technology Considerations:

- Biometric Access Controls

- Card Readers and Access Badges

- Video Surveillance Systems

- Secure Workstation Placement Policies

- User Authentication and Authorization Mechanisms

- Access Control Systems for Software Programs

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?