HEALTHCARE AUDIT PREPARATION CHECKLIST: READINESS & DOCUMENTATION

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--- POLICY AND PROCEDURE REVIEW ---
[ ] Last Policy Review Date
[ ] Policy Version in Use (Version 1.0, Version 1.1, Version 2.0)
[ ] Summary of Recent Policy Updates
[ ] Copy of Current Policy Documents
[ ] Policy Accessibility (Accessible Online, Accessible in Print, Both Online and Print)
[ ] Number of Staff Trained on Current Policies

--- DOCUMENTATION REVIEW ---
[ ] Last Document Review Date
[ ] Summary of Recent Documentation Changes
[ ] Sample Patient Record (Redacted)
[ ] Number of Incident Reports Reviewed
[ ] Completeness of Standard Forms (Complete, Mostly Complete, Needs Improvement)
[ ] Date of Last Patient Record Retention Check
[ ] Description of any identified gaps or inconsistencies

--- ACCESS CONTROLS ---
[ ] Authentication Method (Username/Password, Multi-Factor Authentication (MFA), Biometrics)
[ ] Number of Users with Admin Access
[ ] Data Access Restrictions Applied (Select all that apply) (Role-Based Access Control (RBAC), Attribute-Based Access Control (ABAC), Data Masking, Encryption)
[ ] Last Access Control Review Date
[ ] Password Complexity Requirements Met? (Yes, No, Not Applicable)
[ ] Description of Access Control Procedures

--- TRAINING RECORDS ---
[ ] Last Training Date
[ ] Training Module Completed (HIPAA Privacy, Cybersecurity Awareness, Infection Control, Patient Safety, Emergency Preparedness)
[ ] Training Score (%)
[ ] Training Comments
[ ] Training Certificate
[ ] Trainer Name (Trainer 1, Trainer 2, Trainer 3)

--- BUSINESS ASSOCIATE AGREEMENTS (BAA) ---
[ ] BAA Execution Date
[ ] BAA Type (Standard BAA, Customized BAA)
[ ] Summary of BAA Services
[ ] Copy of Signed BAA
[ ] BAA Status (Active, Expired, Under Review)
[ ] BAA Expiration Date
[ ] Number of Covered Records

--- PHYSICAL SECURITY ---
[ ] Main Entrance Security Checkpoint Location
[ ] Number of Security Cameras Functioning
[ ] Access Badge System Status (Fully Operational, Minor Issues, Significant Issues)
[ ] Date of Last Physical Security Inspection
[ ] Description of Any Identified Physical Security Weaknesses
[ ] Visitor Management System Status (Operational, Needs Review, Not Operational)

--- IT SECURITY ---
[ ] Firewall Rule Count
[ ] Antivirus Software Status (Active, Inactive, Needs Update)
[ ] Last Security Patch Installation Date
[ ] Vulnerability Scan Findings (Select All That Apply) (High Severity, Medium Severity, Low Severity, None)
[ ] Notes on Recent Security Events or Concerns
[ ] Password Policy Compliance (Compliant, Non-Compliant, Needs Review)

--- EMERGENCY PREPAREDNESS ---
[ ] Last Emergency Drill Date
[ ] Scheduled Drill Start Time
[ ] Number of Participants in Last Drill
[ ] Brief Description of Last Drill Scenario
[ ] Drill Outcome (Successful, Requires Improvement, Unsatisfactory)
[ ] Areas Requiring Improvement (Based on Last Drill) (Communication, Evacuation Procedures, Staff Training, Resource Availability, N/A)
[ ] Emergency Contact List (Uploaded File)

--- CORRECTIVE ACTION PLANS ---
[ ] Description of Identified Deficiency
[ ] Date Deficiency Identified
[ ] Severity Level (1-5, 1=Low, 5=High)
[ ] Responsible Department (Clinical, IT, Finance, Compliance)
[ ] Detailed Corrective Action Plan
[ ] Target Completion Date
[ ] Status (Not Started, In Progress, Completed, On Hold)
[ ] Signature of Responsible Party

--- AUDIT TRAIL REVIEW ---
[ ] Start Date of Audit Trail Review
[ ] End Date of Audit Trail Review
[ ] Number of Records Reviewed
[ ] Types of Access Reviewed (e.g., EHR, Billing, Security) (EHR Access, Billing System Access, Security Logs, Pharmacy Records, Lab Results)
[ ] Summary of Findings (e.g., Anomalies, Suspicious Activity)
[ ] Were any unauthorized access attempts detected? (Yes, No)
[ ] Supporting Documentation (Screenshots, Log Exports)

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