Many organizations misunderstand HIPAA Security Risk Assessments (SRAs) and treat them as a one-time compliance task. As a result, they assume they can complete an SRA quickly, document it, and file it away. In reality, auditors and regulators view the SRA as the foundation of your HIPAA Security Rule program. Specifically, it shows whether your organization understands where electronic protected health information (ePHI) lives and what risks could affect it. Additionally, it shows how you are managing those risks over time.

For healthcare providers and business associates, getting the SRA right matters. In practice, it influences everything that follows: safeguards, policies, training, and incident‑response readiness. In this post, we explain what auditors expect from a HIPAA Security Risk Assessment (SRA). Additionally, we will discuss the reasons they review it before technical controls. Furthermore, we explain how to avoid the most common mistakes.

What HIPAA Requires: “Accurate and Thorough” Risk Analysis

The HIPAA Security Rule requires covered entities and business associates to assess potential risks and vulnerabilities to ePHI. In doing so, it ensures they evaluate how those risks could affect the confidentiality, integrity, and availability of that information.

In plain language, an auditor wants clear answers to these questions:

• Where does your organization store, access, or transmit ePHI?
• Which systems, people, and third parties interact with ePHI?
• What threats and vulnerabilities exist in your environment?
• How likely are those risks, and what impact could they have?
• Which safeguards does your organization have in place today?
• Which risks remain, and how does your organization plan to reduce them?

A HIPAA Security Risk Assessment (SRA) does more than identify issues. Ultimately, it documents how your organization evaluates risk and makes security decisions.

Why Auditors Focus on SRAs Before Technical Controls

One of the most important things to understand about HIPAA audits is the role of a Security Risk Assessment (SRA). Without it, an incomplete SRA can undermine every technical safeguard you have in place.

Auditors often cite SRAs early because the risk assessment is the starting point for HIPAA compliance. When that assessment is weak, it raises concerns about how your organization understands risk. This can happen when they omit key systems, overlook third parties, or the risk logic lacks depth. Consequently, the rest of your security program may not be based on a defensible assessment.

Even strong technical controls, such as MFA, encryption, and endpoint security, can raise questions if your organization cannot show:

• Why were those controls determined to be necessary?
• Which risks do those controls mitigate?
• How does the organization track residual risk over time?

In other words, auditors look for the “why” behind your safeguards. Likewise, the SRA is where that justification should live.

What Auditors Actually Expect in a HIPAA Security Risk Assessment

A strong HIPAA SRA follows a clear structure, supports repeatable evaluation, and aligns security decisions with real ePHI workflows. In general, these are the most common expectations auditors look for.

1. Complete ePHI Scope

Auditors expect your SRA to cover all locations where ePHI exists, including:

• EHR systems and clinical applications
• Email systems and file-sharing tools
• Cloud storage platforms
• Workstations, laptops, and mobile devices
• Remote access and VPN environments
• Backups and disaster recovery systems
• Vendor and third-party environments (business associates)

Example: Organizations must include any cloud‑based billing system or third‑party portal that stores or accesses ePHI in scope. Importantly, do not treat it as “outside of IT.”

2. Documented Threat and Vulnerability Identification

An auditor expects you to show that you have evaluated credible threats and weaknesses, not just generic cybersecurity risks.

This includes:

• Threat sources (internal, external, accidental, malicious)
• Common healthcare risks (phishing, ransomware, misconfigurations, improper access)
• Vulnerabilities from technical reviews and operational processes

Example: If staff access ePHI via email or a portal, the SRA should evaluate the related risks. This includes phishing exposure, MFA enforcement, and potential account compromise scenarios.

According to the Verizon 2024 Data Breach Investigations Report (DBIR), the report analyzed 10,626 confirmed breaches globally. As a result, healthcare organizations must maintain an ongoing, documented risk assessment process.

3. Likelihood and Impact

HIPAA SRAs must assess:

• How likely is a risk to occur
• The potential impact on confidentiality, integrity, and availability of ePHI

To meet audit expectations, organizations must use a consistent method they can explain and repeat. That method may be qualitative, such as high, medium, or low, or fully quantitative.

Example: A ransomware risk may affect patient scheduling systems. In that case, the impact can be high due to operational disruption and potential delays in patient care.

4. Risk Scoring and Prioritization

Your SRA should do more than identify risks; it should rank them. Because of this, auditors expect your organization to prioritize risks so remediation stays focused and logical.

Example: Unpatched systems accessing ePHI should score higher than low-impact risks such as unused test accounts in isolated environments.

5. Risk Treatment and Remediation Plan

This is where many organizations struggle. At a minimum, auditors expect:

• Clear remediation steps
• Assigned owners
• Target timelines
• Evidence of progress

Simply put, it is not enough to list risks. You must show a credible plan for reducing them.

Common HIPAA SRA Mistakes That Create Audit Risk

Even well-intentioned organizations fall into similar pitfalls. Fortunately, avoiding these mistakes can dramatically strengthen audit defensibility.

Mistake 1: Treating vulnerability scans as an SRA

Vulnerability scans are useful inputs. However, they do not evaluate business impact, ePHI workflows, or risk treatment planning.

Mistake 2: Missing third-party and vendor scope

In many cases, SRAs fail because they do not include business associate relationships, cloud platforms, or outsourced IT environments.

Mistake 3: Generic findings with no risk logic

For example, statements like “phishing is a risk” are not enough without likelihood, impact, and remediation planning.

Mistake 4: Outdated SRAs

Not surprisingly, auditors quickly flag SRAs that are more than 12 months old. They also raise concerns when SRAs fail to reflect major system or workflow changes.

Mistake 5: No connection between risks and safeguards

Ultimately, auditors want to see how risks drive safeguards, not separate lists that do not align.

How Often Should Your Organization Review and Update HIPAA SRAs?

HIPAA does not prescribe an exact frequency. However, auditors expect SRAs to be:

• Reviewed regularly (often annually as a baseline)
• Updated whenever significant changes occur
• Supported by documentation showing ongoing risk management

A practical approach is:

• Annual full SRA review
• Quarterly review checkpoints
• Change-triggered updates (new systems, vendor changes, incidents, process changes)

This approach aligns with broader SRA best practices across NIST, HITRUST, and SOC 2. These frameworks treat risk assessment as an ongoing program, not a one‑time deliverable.

How This Ties Back to Broader SRA Best Practices

HIPAA may use its own terminology. Even so, the underlying expectations match other frameworks:

• A defined scope and asset inventory
• Threat and vulnerability identification
• Likelihood/impact scoring
• Control mapping and residual risk evaluation
• Treatment plans and ongoing updates

This is why organizations benefit from building a defensible SRA methodology that can map across frameworks. This is particularly true if they support multiple compliance requirements or expect future certifications.

Conclusion

Auditors often review HIPAA Security Risk Assessments (SRAs) first. For this reason, they use the SRA to determine whether your security program rests on a documented, risk‑based foundation. While a strong assessment does not need to be overly complex, it must be accurate, thorough, and actionable. By scoping ePHI correctly, applying consistent scoring, and documenting risk logic, healthcare organizations and business associates create a stronger foundation. Ultimately, this approach supports remediation planning, strengthens compliance, and improves real‑world security maturity.