HIPAA Compliance Checklist for Nephrology Practices

HIPAA compliance isn’t optional for nephrology practices—it’s a legal requirement that carries significant penalties for violations. But nephrology faces compliance challenges that general medical practices don’t encounter: constant lab result transmission, complex dialysis center coordination, and extensive sharing of protected health information (PHI) across multiple care settings.

This checklist covers the HIPAA essentials every nephrology practice needs to address, with specific attention to the unique data flows and risks in kidney care.

Understanding HIPAA’s Core Requirements

Before diving into the checklist, let’s review what HIPAA actually requires:

The Privacy Rule governs how PHI can be used and disclosed. It establishes patient rights and limits on information sharing.

The Security Rule requires administrative, physical, and technical safeguards for electronic PHI (ePHI). This includes risk analysis, access controls, and encryption.

The Breach Notification Rule requires notification to patients, HHS, and sometimes media when unsecured PHI is breached.

The Enforcement Rule establishes penalties for violations, which can reach millions of dollars for willful neglect.

Part 1: Risk Analysis and Management

HIPAA requires a thorough risk analysis—not a one-time event, but an ongoing process.

Initial Risk Analysis

Identify all locations where PHI is stored (paper and electronic)
Map how PHI flows through your practice (intake → records → labs → referrals)
Identify all systems that contain ePHI
Document potential threats and vulnerabilities
Assess current security measures
Prioritize risks based on likelihood and impact
Create a risk remediation plan

Ongoing Risk Management

Review and update risk analysis annually (minimum)
Reassess after significant changes (new systems, new locations, etc.)
Document all risk decisions and remediation actions
Track remediation progress

Nephrology-Specific Considerations

Your risk analysis should specifically address:

Lab result transmission security (incoming and outgoing)
Dialysis center data sharing
Referral communication with PCPs and other specialists
Patient portal security
Remote access for physicians (hospital rounds, on-call)

Part 2: Administrative Safeguards

These are the policies, procedures, and practices that govern how your workforce handles PHI.

Policies and Procedures

Written HIPAA Privacy Policy
Written HIPAA Security Policy
Breach notification procedures
Sanctions policy for violations
Workforce access policy (who can access what)
Device and media handling policy
Disaster recovery and contingency plan

Security Officer Designation

Designated Privacy Officer (can be same person)
Designated Security Officer
Clear documentation of their responsibilities
Adequate authority to implement compliance

Workforce Training

Initial HIPAA training for all new employees
Annual refresher training for all staff
Role-specific training (front desk, clinical, billing)
Training documentation and records
Training on recognizing phishing and social engineering

Access Management

Unique user IDs for all system access
Role-based access controls (minimum necessary)
Process for granting access to new employees
Process for revoking access when employees leave
Periodic access reviews (who has access to what?)

Learn more about HIPAA compliance for nephrology

Part 3: Physical Safeguards

Physical security of locations where PHI is accessible matters—especially in busy clinical environments.

Facility Access

Secure entry to areas containing PHI
Visitor policies and sign-in procedures
Workstation positioning (screens not visible to patients)
Clean desk policies (no PHI left visible)

Workstation Security

Automatic screen lock after inactivity
Workstations positioned away from public view
Privacy screens where needed
No unauthorized software installation

Device and Media Controls

Inventory of all devices containing ePHI
Encryption on all portable devices (laptops, tablets, phones)
Secure disposal procedures for old equipment
Secure destruction of media containing PHI
Procedures for lost or stolen devices

Paper Records

Secure storage for paper records
Locked filing cabinets when not in use
Secure shredding for PHI disposal
Fax machine security (not in public areas)

Part 4: Technical Safeguards

These protect ePHI through technology controls.

Access Controls

Unique user identification
Automatic logoff
Encryption in transit (TLS/SSL)
Encryption at rest (stored data)
Multi-factor authentication (highly recommended)

Audit Controls

System activity logs
Login attempt monitoring
Access to PHI logging
Regular log review procedures

Integrity Controls

Mechanisms to verify ePHI hasn’t been improperly altered
Backup verification processes
Data integrity checks

Transmission Security

Encrypted email for PHI (or secure patient portal)
Secure fax transmission (or encrypted fax-to-email)
Secure file transfer protocols
VPN for remote access

Learn about HIPAA-compliant fax solutions

Part 5: Lab Result Handling

Lab results are the lifeblood of nephrology—and a significant compliance risk area.

Incoming Lab Results

Secure transmission from laboratories (encrypted connections)
Verification procedures for received results
Prompt incorporation into patient records
Flagging and workflow for critical values

Outgoing Lab Orders

Secure transmission to laboratories
Verification of correct patient identification
Documentation of orders sent

Lab Business Associate Agreements

Current BAAs with all laboratories you use
BAA review when relationships change
Documentation of lab compliance verification

Part 6: Dialysis Center Coordination

If your practice coordinates with dialysis centers, this creates significant data sharing that requires compliance attention.

Business Associate Agreements

BAAs with all dialysis centers where your patients receive treatment
Clear scope of permitted PHI sharing
Breach notification provisions
Annual review of BAAs

Defined what information is shared and how
Secure transmission methods for patient data
Access controls for shared patient information
Procedures for addressing discrepancies

For Practices That Own/Operate Dialysis Centers

Separate compliance programs if required
Clear policies for information flow between practice and dialysis
Appropriate access segmentation

Part 7: Referral and Care Coordination

Nephrology involves extensive coordination with other providers—each interaction involves PHI.

Referral Communications

Secure methods for receiving referral information
Secure methods for sending consult notes back
Minimum necessary standard applied (don’t send more than needed)
Verification of recipient identity before sending PHI

Care Coordination

Secure communication with PCPs
Secure communication with hospitals
Secure communication with transplant centers
Documentation of disclosures

Patient Portal

Secure patient portal meeting HIPAA requirements
Strong authentication for patient access
Encryption of portal data
Audit logging of portal access

Part 8: Business Associate Management

Any vendor that handles PHI on your behalf requires a Business Associate Agreement.

Common Nephrology Business Associates

BAA Requirements

Written BAA in place before PHI is shared
BAA includes required HIPAA provisions
Annual review of BAA inventory
Process for handling BA breaches
Documentation of BA compliance verification

Learn about IT services for healthcare

Part 9: Breach Response

Despite best efforts, breaches can happen. Being prepared is essential.

Breach Response Plan

Written breach response procedures
Clear roles and responsibilities
Contact information for response team
Templates for required notifications

When a Breach Occurs

Incident documentation procedures
Risk assessment process (did breach require notification?)
Notification procedures (patients, HHS, media if applicable)
Timeline compliance (60 days for patient notification)
Corrective action documentation

Documentation

Maintain breach log for 6 years
Document all breaches (even those not requiring notification)
Document risk assessments and decisions
Retain all breach-related communications

Part 10: Documentation and Record Keeping

HIPAA requires extensive documentation, retained for 6 years.

Required Documentation

Documentation Best Practices

Consistent dating and versioning of policies
Clear indication of when policies were reviewed/updated
Organized, accessible storage of compliance documents
Regular audits of documentation completeness

Part 11: Patient Rights

HIPAA grants patients specific rights that your practice must honor.

Required Capabilities

Process for patients to access their records
Process for patients to request amendments
Process for patients to request restrictions
Process for patients to request alternative communications
Accounting of disclosures capability
Notice of Privacy Practices distribution

Notice of Privacy Practices

Current NPP compliant with HIPAA
NPP provided to all patients
Good faith effort to obtain acknowledgment
NPP posted in office
NPP available on website

Annual Compliance Review

HIPAA compliance isn’t one-and-done. Schedule annual reviews:

Nephrology-Specific Red Flags

Watch for these common compliance gaps in nephrology practices:

Lab results via unsecured email — Use encrypted email or portal only
Dialysis coordination via fax without BAA — Ensure BAAs with all dialysis centers
Dictation services without BAA — Transcription services are business associates
Remote access without VPN — Physicians accessing records from home or hospital need secure connections
Missing BAA with IT support — Your IT provider likely accesses ePHI
Outdated patient portal security — Ensure your portal meets current security standards

Need Help with HIPAA Compliance?

HIPAA compliance is complex, and nephrology adds layers of complexity. At MedTech Consulting, we help nephrology practices implement and maintain HIPAA compliance programs.

Our services include risk assessments, policy development, staff training, and technical safeguard implementation.