Dental Assisting National Board General Chairside (DANB GC)

Correct: Under the HIPAA Breach Notification Rule (45 CFR 164.400-414), any unauthorized acquisition, access, use, or disclosure of PHI is presumed to be a breach unless the covered entity demonstrates a low probability that the PHI has been compromised. This must be supported by a documented risk assessment considering four specific factors: the nature and extent of the PHI, the unauthorized person involved, whether the PHI was actually acquired or viewed, and the extent of risk mitigation. Documentation of this assessment is mandatory if the entity decides not to provide notification.

Incorrect: Relying on password protection or remote wipe capabilities is insufficient for the ‘safe harbor’ provision, which specifically requires NIST-standard encryption to exempt an entity from the breach rule. Internal incident reports, while necessary for administrative tracking, do not satisfy the regulatory requirement for a multi-factor risk assessment to justify non-notification. The number of records involved (the 500-record threshold) only dictates the timing and method of reporting to the HHS Secretary and the media; it does not exempt the entity from the requirement to notify individuals or to document the risk assessment if they choose not to notify.

Takeaway: To legally justify not issuing a HIPAA breach notification, a covered entity must document a formal risk assessment proving a low probability of PHI compromise based on four regulatory factors.

Correct: The HIPAA Security Rule requires covered entities to implement technical safeguards, including access controls and audit controls. Role-based access control (RBAC) ensures that users only access the minimum necessary information required for their job functions. Automated audit log reviews provide a proactive method to detect and respond to unauthorized access or modifications, addressing both internal threats and compliance requirements for maintaining the integrity of clinical documentation.

Incorrect: Relying only on training and agreements is an administrative safeguard but is insufficient without technical controls to prevent or detect breaches. Focusing only on external threats ignores the significant risk of internal unauthorized access, which is a core component of HIPAA compliance. Moving to physical archives is impractical in a modern clinical setting and does not address the security requirements for documentation that must remain accessible for patient care, nor does it inherently satisfy HIPAA’s digital security standards for existing electronic records.

Takeaway: Effective HIPAA security compliance requires a combination of technical access controls and continuous monitoring of audit logs to ensure the integrity and confidentiality of clinical documentation.

Correct: The HIPAA Privacy Rule requires covered entities and business associates to take reasonable steps to limit the use or disclosure of, and requests for, PHI to the minimum necessary to accomplish the intended purpose. Documenting the justification for access levels and performing periodic reviews ensures that access is tailored to specific roles and terminated when no longer required, fulfilling both the minimum necessary standard and administrative safeguard requirements for access control and termination.

Incorrect: Non-disclosure agreements are general legal documents and do not replace the specific regulatory requirements of a BAA under HIPAA. Personal approval of every request by a CIO is an inefficient administrative burden that does not address the underlying documentation of access rights or the failure to terminate access. Read-only access limits modification but does not address the minimum necessary disclosure or the failure to revoke access upon contract termination.

Takeaway: Effective HIPAA compliance requires documented justification for PHI access levels and rigorous administrative procedures for the timely termination of access rights for third-party associates.

Correct: The HIPAA Security Rule (45 CFR § 164.312(a)(2)(i)) requires unique user identification as a standard. Even during emergency operations, the entity must ensure that actions can be attributed to a specific user. Conducting a retrospective audit to identify who used the shared account and then updating the business continuity plan to ensure unique IDs are available during emergencies addresses both the immediate compliance gap and the systemic failure in the documentation process.

Incorrect: Prohibiting emergency credentials entirely is impractical and contradicts the HIPAA requirement for an emergency mode operation plan. Labeling the violation as a justified exception is incorrect because unique identification is a required implementation specification that cannot be bypassed for administrative convenience. Increasing password rotation frequency addresses credential security but fails to satisfy the core requirement for individual accountability and auditability of specific user actions within the ePHI environment.

Takeaway: HIPAA Security Standards require unique user identification and audit controls even during emergency business continuity events to ensure individual accountability for ePHI access.

Correct: Under the HIPAA Breach Notification Rule (45 CFR §§ 164.400-414), for breaches affecting 500 or more individuals, the covered entity must notify the affected individuals, the Secretary of HHS, and prominent media outlets serving the jurisdiction. These notifications must be made without unreasonable delay and no later than 60 days following the discovery of the breach. Documentation must be maintained to prove that all three required notifications were executed within the legal timeframe to satisfy the burden of proof requirements.

Incorrect: Delaying notification until a forensic investigation identifies a specific perpetrator is not a valid reason for exceeding the 60-day regulatory deadline. Annual reporting to the Secretary of HHS is only permitted for breaches affecting fewer than 500 individuals; breaches of 500 or more require immediate notification. Bypassing media notification for a breach of 525 individuals is a direct violation of the rule, regardless of the organization’s desire to protect its reputation or focus on future corrective actions.

Takeaway: Breaches involving 500 or more individuals require documentation of notifications to individuals, the Secretary of HHS, and the media within a strict 60-day window.

Correct: Under the HIPAA Breach Notification Rule (45 CFR §§ 164.400-414), any unauthorized use or disclosure of PHI is presumed to be a breach unless the covered entity or business associate demonstrates a low probability that the PHI has been compromised. This must be supported by a documented risk assessment of at least four factors: the nature and extent of the PHI, the unauthorized person who used the PHI or to whom the disclosure was made, whether the PHI was actually acquired or viewed, and the extent to which the risk to the PHI has been mitigated.

Incorrect: A simple log with a signed statement is insufficient because it does not address the specific four-factor analysis required by federal regulations to prove a low probability of compromise. Notification to the OCR within 60 days is only mandatory for breaches affecting 500 or more individuals; for smaller incidents, notification is required annually, and if the incident is determined not to be a breach, no OCR notification is required at all. A Business Associate Agreement (BAA) defines responsibilities but does not exempt a provider from the documentation requirements of the Breach Notification Rule when a potential disclosure occurs.

Takeaway: To justify not notifying individuals of a PHI disclosure, a covered entity must document a thorough four-factor risk assessment proving a low probability of compromise.

Correct: Under the HIPAA Privacy Rule’s Safe Harbor method for de-identification, 18 specific identifiers must be removed from the health information. This includes all geographic subdivisions smaller than a state, including street address, city, county, and zip code (with a very specific exception for the first three digits of a zip code if the geographic unit formed by those digits contains more than 20,000 people). Additionally, all elements of dates (except year) for dates directly related to an individual, including birth date, admission date, discharge date, and date of death, must be removed.

Incorrect: Retaining full zip codes or full dates of birth violates the Safe Harbor method requirements for de-identification. While a Business Associate Agreement (BAA) is necessary for sharing PHI with vendors, it does not de-identify the data; the data remains PHI and subject to all HIPAA protections. Masking only the day and month of birth is insufficient because the Safe Harbor method specifically requires the removal of all date elements more granular than the year. Using unique tracking codes (pseudonymization) is a security measure but does not constitute de-identification if the underlying identifiers like full birth dates are still present.

Takeaway: To achieve de-identification via the Safe Harbor method, all specific geographic identifiers smaller than a state and all date elements more specific than a year must be removed or modified.

Correct: The HIPAA Security Rule requires specific technical safeguards, including unique user identification and audit controls, to ensure that PHI is not improperly altered or destroyed. When documentation functions are outsourced, the covered entity must ensure the business associate maintains documentation that proves these controls are active and verifiable. Providing an encrypted audit trail is essential for maintaining the integrity of the inpatient medical record and meeting the technical safeguard requirements of 45 CFR 164.312.

Incorrect: Relying on international standards like ISO 27001 is insufficient because these certifications do not legally replace the specific regulatory requirements of HIPAA. Manual spot-checks of login timestamps are an administrative monitoring tool but do not satisfy the technical safeguard requirement for automated access controls and system-generated audit trails. Shifting legal liability through an indemnification clause does not satisfy the regulatory requirement to ensure that technical safeguards are actually implemented and documented by the business associate.

Takeaway: HIPAA compliance in outsourced documentation requires verifiable technical safeguards, including unique user identification and audit trails, which cannot be replaced by general security certifications or liability shifts.

Correct: The best next step is to perform a root cause analysis. In a professional audit or compliance environment, identifying the source of the problem—whether it is a technical failure in how the EHR is configured, a lack of clinician awareness regarding privacy standards, or an outdated policy—is essential for developing an effective corrective action plan. This systematic approach ensures that the remedy addresses the actual cause rather than just the symptom.

Incorrect: Suspending all clinician access is an overreaction that could jeopardize patient safety and does not address the underlying cause of the documentation issue. Reporting to the Office for Civil Rights is premature; an internal investigation must first determine if the incident meets the regulatory definition of a reportable breach under the HIPAA Breach Notification Rule. Deleting medical records is a violation of record retention standards and moving to paper charts is a regressive step that fails to solve the compliance challenge within the digital infrastructure.

Takeaway: A systematic root cause analysis is the foundational step in addressing HIPAA documentation deficiencies to ensure corrective actions are targeted and effective.