HIPAA Compliance Checklist: What Every Medical Practice Should Review in 2025

As we move deeper into 2025, reviewing a HIPAA compliance checklist 2025 is a critical responsibility for medical practices. The HIPAA Security Rule, established by the U.S. Department of Health and Human Services (HHS), sets national standards for safeguarding electronic protected health information (ePHI). Compliance with this rule has never been more important as the healthcare landscape faces a growing number of challenges, including:

• Ransomware attacks targeting healthcare organizations of all sizes
• AI misuse that could expose or infer sensitive patient information
• Vulnerabilities in expanded digital workflows such as electronic health record (EHR) integrations, telehealth platforms, and secure patient portals

These new ways of delivering care improve efficiency and patient experience, but they also create more entry points for cyberattacks if not properly secured. This checklist will guide medical practices through key HIPAA requirements to review this year.

1. Conduct a Thorough Security Risk Assessment (SRA)

Conducting Security Risk Assessments (SRAs) is the foundation of HIPAA compliance. It’s the process that helps a medical practice identify vulnerabilities and determine what safeguards are needed to meet the standards of the Security Rule. According to the HHS, a proper assessment must be both accurate and thorough, evaluating all potential risks to the confidentiality, integrity, and availability of ePHI held by the medical practice. Inadequate or outdated SRAs are one of the most common HIPAA violations leading to enforcement actions. HHS guidelines recommend that practices must conduct documented, in-depth SRAs annually and after any significant technological change.  How Tower 23 IT can help Many medical practices lack the time or in-house expertise to complete a comprehensive SRA. Tower 23 IT provides managed HIPAA risk assessment services, ensuring that your practice:

• Identifies vulnerabilities across systems, networks, and workflows
• Documents compliance gaps and provides remediation recommendations
• Produces audit-ready reports aligned with HHS expectations
• Reviews assessments regularly to keep pace with changing threats

2. Designate a HIPAA Compliance Officer — Privacy & Security

Every medical practice must designate individuals to oversee HIPAA compliance. While smaller practices sometimes combine these responsibilities into one role, larger organizations often appoint separate officers for privacy and security. These appointments are not optional — the HIPAA Privacy Rule and Security Rule both explicitly require covered entities to designate responsible officials.

• Privacy Officer Responsible for developing and implementing privacy policies, ensuring patients’ rights of access to their records, updating Notices of Privacy Practices, and serving as the point of contact for privacy complaints or inquiries.
• Security Officer Oversees the technical and administrative safeguards that protect electronic protected health information (ePHI). Duties include managing access controls, monitoring for potential breaches, coordinating risk assessments, and leading incident response efforts.

Together, these officers provide accountability, help ensure compliance with federal regulations, and prepare the practice for audits or investigations.  How Tower 23 IT can help Tower 23 IT's Managed Security service can help medical practices implement a comprehensive computer network defense scheme that goes beyond running basic antivirus applications. Tower 23 IT's robust, two-tiered security program constantly assesses risks, eliminates vulnerabilities, and makes sure your medical practice keeps your ePHI protected.

3. Keep Policies, Procedures, and Documentation Up to Date

Written policies and procedures are the backbone of HIPAA compliance. The HIPAA Privacy, Security, and Breach Notification Rules all require medical practices to create, maintain, and regularly update documentation that demonstrates how compliance is carried out in practice. Having these documents is not enough— the HHS Office for Civil Rights (OCR) expects them to be reviewed, tested, and followed in day-to-day operations.

• Core Documentation Requirements Practices must maintain current records of:
  • Privacy and security policies
  • Workforce training logs
  • Network maps and system inventories
  • Incident response and breach notification plans
  • Risk assessment reports

Outdated templates are a common reason medical practices fail audits. Instead, follow a structured HIPAA compliance checklist 2025 that reflects your actual workflows.

• Practical Steps for Compliance
  • Conduct annual policy reviews and update language to reflect new threats (such as AI, telehealth platforms, and reproductive health privacy rules).
  • Test policies through exercises like mock breaches or audit log reviews to ensure they are practical, not just paperwork.
  • Assign ownership to specific individuals: your Privacy and Security Officers (see Section 2) should be responsible for keeping documentation current and audit-ready.

How Tower 23 IT can help Tower 23 IT’s Audits and Documentation service can help medical practices complete a full accounting of their IT infrastructure and maintain audit-ready documentation.

4. Staff Training & Workforce Awareness

• Annual + Onboarding Training HIPAA requires every staff member—whether clinical, administrative, or IT—to receive training upon hire and at least annually thereafter. Training should cover the Privacy Rule, Security Rule, and Breach Notification Rule requirements.

• Emerging Topics for 2025 Training is most effective when updated for current threats. In 2025, staff education should emphasize:

• Phishing awareness (simulated phishing campaigns are highly effective)

• Ransomware prevention (safe handling of email attachments, external devices)

• AI and Chatbot use (preventing unintentional PHI disclosures)

• Third-party apps and telehealth tools (proper handling of ePHI in remote care)

• Practical Tip: Maintain detailed training logs (dates, topics, and staff signatures). OCR frequently requests this documentation during investigations.

How Tower 23 IT can help Tower 23IT can deliver customized training and phishing simulations tailored for healthcare staff, ensuring compliance while keeping the team alert.

5. Implement Strong Technical Safeguards

• Encryption & Multi-Factor Authentication (MFA) Notice of Proposed Rulemaking (NPRM) is a process used by federal agencies like the HHS to propose updates to HIPAA regulations before finalizing them. The 2025 NPRM proposes making both encryption and MFA mandatory, not just recommended best practices.

• Other Technical Measures

• Role-based access control: Ensure staff only access the “minimum necessary” information.

• Automatic logoff & session timeouts: Reduce the risk of unattended workstation breaches.

• Audit controls: Keep logs of access to ePHI and review them regularly for suspicious activity.

• Timely software updates: Update key software in a timely manner. Outdated software is a leading cause of healthcare breaches.

• Practical Tip: Document every safeguard in your HIPAA compliance plan. OCR doesn’t just want to see that controls exist—they want proof that they are reviewed and updated.

6. Review Business Associate Agreements (BAAs)

• Why BAAs Matter Any vendor that handles PHI—such as cloud hosting providers, billing services, or IT consultants—must sign a Business Associate Agreement (BAA). OCR has penalized practices for failing to have BAAs in place, even when no breach occurred.

• Key Elements of a Strong BAA

• • • Vendor must implement HIPAA-compliant safeguards.
    • Vendor must notify the covered entity of breaches within the required timeframe.
    • Responsibility for subcontractors handling PHI must be defined.

• 2025 Update: The NPRM proposes stronger vendor accountability, including 24-hour notification requirements for major incidents.

7. Incident Response and Breach Notification Planning

• Why It’s Critical Breaches are no longer a matter of if, but when. OCR requires every medical practice to have a written incident response plan that covers detection, reporting, containment, and recovery.

• Key Plan Components

• • • Defined roles and responsibilities in case of an incident
    • Steps for containing and mitigating damage
    • Clear breach notification procedures (patients, HHS, and sometimes media within 60 days)
    • Coordination with law enforcement or cybersecurity experts, if needed

• Practical Tip: Run tabletop exercises at least annually to test your plan. OCR looks favorably on practices that can demonstrate preparedness.

8. Ensure Patient Rights and Access

• The Access Rule Patients have the right to access their medical records promptly, usually within 30 days. Delays or unnecessary denials are among the most common HIPAA enforcement actions.

• 2025 Considerations:

• • • Align with Information Blocking rules under the 21st Century Cures Act, which prohibit unreasonable interference with access to electronic health information.
    • Provide records in the format requested, if possible (e.g., electronic copies via secure portal).

• Ensure staff understand what constitutes a “reasonable cost-based fee” for copies.

How Tower 23 IT can help A strong patient portal with secure access reduces manual work and helps ensure compliance. Tower 23 IT can implement HIPAA-compliant portals and telehealth platforms that streamline patient access.

9. Address Emerging Technologies & Privacy Concerns

• AI and Machine Learning Risks OCR is closely examining how AI tools may inadvertently expose PHI—for example, by generating outputs based on sensitive data. Any AI use in clinical or administrative workflows must be governed by policies.

• Tracking Technologies Tools like website cookies, session trackers, and online analytics may be considered disclosures of PHI if tied to patient portals. Review OCR’s guidance on tracking technologies to ensure compliance.

• Reproductive Health Privacy In December 2024, HHS finalized rules strengthening protections for reproductive health data. By February 16, 2026, medical practices must update their Notices of Privacy Practices (NPPs) to reflect these changes.

• Practical Tip: Schedule an annual technology audit to review new platforms (AI, telehealth, cloud apps) for HIPAA compliance gaps.

10. Maintain Audit Readiness

OCR’s audit program has intensified, with 2024–2025 audits focusing heavily on ransomware readiness and Security Rule safeguards.

• Audit Readiness Checklist

• • • Keep copies of your last Security Risk Assessment (SRA) and remediation plan.
    • Maintain workforce training logs.
    • Document your policies, procedures, and incident response plans.

• Be prepared to show evidence of technical safeguards (e.g., encryption, and MFA).

• Practical Tip: Treat “audit readiness” as an ongoing process, not a scramble when OCR comes knocking.

Tower 23 IT: Your Trusted HIPAA Partner

In 2025, HIPAA compliance requires more than ticking off a checklist—it demands a structured, documented, and adaptive approach. Proactively managing risk, updating policies and training, and staying responsive to new rules (like those around AI, tracking, and reproductive data) will be essential. With its comprehensive healthcare industry services, Tower 23 IT is equipped to assist with every step—from risk assessments and staff training to incident response and compliance documentation. Want to get started? Contact us to explore how we can tailor HIPAA compliance solutions to your practice.

Tower 23 IT HIPAA Compliance Checklist 2025 - CHART

What Every Medical Practice Should Review This Year

Area	Key Tasks & Considerations
Risk Assessment (SRA)	Conduct annual + event-triggered SRAs  Use HHS/ONC SRA tools or NIST frameworks  Document vulnerabilities and remediation plans
Compliance Officer	Appoint Privacy & Security Officers (required by HIPAA)  Define roles & responsibilities  Ensure accountability and audit readiness
Policies & Documentation	Maintain updated privacy/security policies, training logs, network maps, incident response plans  Review annually and after system changes  Test policies with mock audits or breach drills
Staff Training	Train all staff at hire + annually (Privacy, Security, Breach Notification Rules)  Simulate phishing attacks  Add 2025 topics: AI, ransomware, telehealth tools  Keep signed training logs
Technical Safeguards	Encrypt PHI at rest and in transit  Enable Multi-Factor Authentication (MFA)  Use role-based access controls  Apply automatic logoff/session timeouts  Patch and update systems regularly
Business Associate Agreements (BAAs)	Maintain signed Business Associate Agreements for all vendors handling PHI  Include breach notification timelines (NPRM proposes 24 hours) Monitor vendor compliance and subcontractor use
Incident Response	Maintain a written incident response and disaster recovery plan  Define roles and responsibilities  Conduct tabletop breach exercises annually  Follow breach notification rules (60-day max)
Patient Access	Provide patient records within 30 days (often faster)  Support multiple formats (electronic, paper, portal)  Comply with Information Blocking rules  Charge only cost-based fees
Emerging Tech & Privacy	Audit AI and machine learning use for PHI risks  Review online tracking tools (cookies, analytics)  Update Notices of Privacy Practices (NPPs) for reproductive health protections by Feb 2026
Audit Readiness	Keep SRA documentation and remediation plans  Maintain current training logs  Document technical safeguards (encryption, MFA, access logs)  Treat readiness as ongoing, not one-time prep