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HIPAA SRA: Turn a Year of Work into Proof

October’s final week is more than a calendar milestone. It’s your Q4 closeout window and the last lap of Cybersecurity Awareness Month. If you tightened controls, ran trainings, tuned backups, and fixed findings across 2025, your HIPAA Security Rule Risk Analysis (SRA) file should show it.

Auditors, partners, and boards increasingly expect decisions plus evidence, not just policy prose. And with healthcare breach impacts measured in months to contain and millions of dollars in losses, an SRA that captures what really changed this year isn’t paperwork—it’s protection and proof. Use this week to assemble a clean, auditable SRA package that shortens renewals, reduces back-and-forth, and locks in your Q1 plan.

The Binder That Speaks for You

Give your SRA a simple eight-tab structure. Each tab gets a short summary, 3–5 bullets, one screenshot callout, and an owner/date line.

• Scope & Method
  What systems, data types, facilities, and third parties you evaluated—and the approach (asset-based, control-based, or hybrid).
  Proof to keep: one-page scope diagram + methodology note.

• Risks & Decisions
  Top risks, owners, target dates, and accept/mitigate/transfer decisions captured clearly.
  Proof to keep: risk register export with statuses and next actions.

• Identity & MFA
  MFA/SSO coverage, privileged access list, passkey pilot notes where applicable.
  Proof to keep: coverage screenshot + admin roster snippet.

• Training
  Courses delivered (HIPAA, phishing, role-based), completion rates, refresh cadence.
  Proof to keep: LMS export + last reminder email.

• Patching & Hardening
  High-impact fixes shipped (e.g., VPN hardening, email auth, EDR rollout).
  Proof to keep: before/after config screenshots + change log excerpt.

• Backups & Recovery
  One successful restore test with date, steps, result, and approver sign-off.
  Proof to keep: timestamped restore screenshots + approval note.

• Incidents & Lessons
  Summaries (including near-misses), root causes, and the control updates you made.
  Proof to keep: one-page PIR + linked change ticket.

• Approvals & Attestations
  Leadership sign-off, documented risk acceptances, key BAAs/DPAs on file.
  Proof to keep: signed memo or ticket comment (name, title, date).

Evidence, Not Essays

Keep artifacts short, dated, and owned.

• One screenshot or export > one paragraph of description.

• Redactions are fine—note what and why.

• Put owner + date on every artifact.

• Link out to living systems (LMS, ticketing, MDM) instead of pasting walls of text.

Slowdowns to Avoid

A tight file prevents rework.

• Risks with no named owner or next action.

• No signed restore test or missing results.

• MFA “planned” with no coverage proof.

• Training claims without completion exports.

• “Lessons learned” with no mapped control change.

If you use an SRA tool or worksheet to organize, great—just remember the artifact pack is the hero. Forms help you think; evidence proves you did the work.

VanRein Compliance Closes the Loop

Turn 2025 effort into defensible proof with a guided finish. VanRein Compliance helps you prepare, package, and present an SRA file auditors and partners will appreciate:

• Gap Snapshot & Owners – Clear list of missing artifacts with due dates.

• Identity & Access Proof – MFA coverage exports, privileged access attestations, passkey pilot notes.

• Training Evidence – LMS completions by role, course catalog, renewal cadence.

• Patching & Hardening Pack – Before/after screenshots, change approvals, high-impact fixes called out.

• Backup & DR Proof – Documented restore test with screenshots and executive sign-off.

• Incident to Control Mapping – One-page PIRs tied to specific control updates.

• Leadership Sign-Off – Executive memo template to finalize the 2025 SRA and accept residual risks.

• Q1 Action Plan – Pre-assigned owners/dates for carry-forward items (e.g., vendor attestations, access recerts).

Q1 Starts Now

Close Q4 by capturing what changed this year and pre-assigning next steps: which risks move, which controls mature, and which vendors need new attestations. Your SRA then becomes a living plan, not a once-a-year exercise.

A clean, eight-tab SRA file turns your 2025 effort into defensible proof. It shortens audits, clarifies priorities, and gives leadership confidence that security isn’t just promised—it’s practiced.

👉 Schedule a Discovery Call to lock in your SRA Closeout Session and enter Q1 with clarity and proof. We will help you finish strong: we review your evidence, fill critical gaps, and package a binder you can hand to leadership or auditors.

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AI Governance Mini-Review:
45 Minutes to Keep Your Guardrails Real

Q4 closeout isn’t just for HIPAA—your AI policy needs proof it’s alive. As teams lean on copilots, summarizers, and analytics, risk shifts quickly: prompts drift, tools change, and PHI can creep into places it shouldn’t. A lightweight, repeatable mini-review turns governance into practice you can show to leadership, customers, and auditors—without slowing anyone down.

This Week’s Three Checks

Run these now and capture one artifact per check. Small proof beats long memos.

• Approved Tools, Up to Date
  Confirm what’s allowed (and what’s not), note versions, and tag tools that touch PHI with a Business Associate Agreement (BAA) on file.
  Proof to keep: one-page “Approved Tools” list (date, owner, last change).

• PHI-Safe Prompt Rules, Posted and Understood
  Keep do/don’t examples where people actually work (LMS card, wiki, chat pin).
  Proof to keep: screenshot of the posted rules + training link.

• Logging On and Reachable
  Ensure prompts/outputs are logged for approved tools with a reasonable retention period and that privacy/security owners can access them.
  Proof to keep: single log excerpt (redacted), date, reviewer initials.

Six Yes/No Rubrics That Stick

Answer each, assign an owner, and set a due date if “No.”

• We know which teams can use AI and for what tasks.

• PHI in prompts is blocked by default unless using an approved, BAA-covered environment.

• Staff can find do/don’t prompt examples in one click.

• Logs are accessible to the privacy/security owner on request.

• There’s a clear escalation path if PHI leaks into an unapproved tool.

• Today’s review is recorded with follow-ups and target dates.

Carry-Forward Rhythm

A light cadence keeps you ahead of drift and scope creep.

• Monthly: update tools list; spot-check logs; refresh prompt examples.

• Quarterly: vendor attestations (no-training, retention, region); change review for risky use cases.

• Biannual: bias/fairness pulse check where relevant; management review note to leadership.

Evidence Auditors Respect

Short, dated, and owned—designed to travel across HIPAA, SOC 2, ISO 27001, and ISO/IEC 42001.

• Current AI policy (version/date/owner)

• Approved tools list with PHI flags and BAA status

• 3–5 sanitized prompt/output examples showing rules in practice

• A review log entry from today (decisions + next steps)

• Relevant vendor attestations or DPAs/BAAs

VanRein Compliance Makes It Routine

Turn your policy into a working cadence with help that fits real teams.

• Mini-Review Facilitation: we run the first 45-minute session, capture decisions, and hand back a one-page review log.

• Templates & Playbooks: approved-tools register, PHI-safe prompt rules, change/review checklist.

• Training Boosters: micro-modules that reinforce safe prompts and PHI hygiene.

• Vendor Governance Support: attestations (no-training, retention, region), BAA/DPA checks, and a simple renewal rhythm.

• Remediation Hand-Off: quick actions for “No” answers (blocklists, access tweaks, posting updates) with owners and dates.

Bottom Line

Freeze today’s snapshot, assign the follow-ups, and put the next mini-review on the calendar. When your AI guardrails are visible, reviewed, and evidenced, you reduce surprises, earn stakeholder trust, and walk into 2026 with governance you can prove any day of the year.

Partner with VanRein Compliance today and make AI governance repeatable through guided sessions. We’ll facilitate your mini-reviews, finalize your tools list and PHI-safe rules, and deliver an evidence pack you can reuse.

👉 Reply “AI-REVIEW” to get the mini-review kit and schedule your session to map a quarter-by-quarter governance cadence tailored to your team.

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