HIPAA PP-4.3: Device and Media Controls — Accountability
HIPAA Security Rule PP-4.3 requires healthcare organizations to document and track the movement of all hardware and electronic media, ensuring accountability for protected health information (PHI) at every step. This control prevents unauthorized access, loss, or theft of sensitive data by maintaining a clear chain of custody. Without proper device and media tracking, your organization faces regulatory penalties and increased breach risk.
What this means
Device and Media Controls — Accountability mandates that your organization establish and maintain detailed records documenting the physical movement, location, and responsible parties for all hardware devices and electronic media storing or processing PHI. This includes laptops, servers, USB drives, backup tapes, and other storage media. You must be able to prove who had possession of each device at any given time, creating an auditable trail that demonstrates accountability and control over your most sensitive assets.
How to comply
- 1.Create a device and media inventory system that captures device type, serial number, storage location, and assigned owner or custodian
- 2.Implement a movement log or tracking mechanism documenting when devices are transferred between departments, employees, or secure locations
- 3.Assign specific individuals responsibility for each device and require sign-offs when custody transfers occur
- 4.Establish a retention schedule for device movement records aligned with your data retention policies
- 5.Conduct regular audits (quarterly or semi-annually) comparing physical inventory against documented records to identify discrepancies
- 6.Document the disposal or decommissioning of all hardware and media, including sanitization methods and certification of data destruction
Evidence auditors look for
- Device inventory spreadsheet with serial numbers, asset tags, storage locations, and assigned custodians
- Equipment movement logs showing transfer dates, from/to locations, and authorized personnel signatures
- Chain of custody forms documenting hardware reassignments between departments or employees
- Physical audit reports comparing actual device inventory to documented records with reconciliation notes
- Device decommissioning certificates showing sanitization methods and completion dates
- Access logs from secure storage facilities (server rooms, locked cabinets) showing who accessed devices and when
- Records of storage media checkout/check-in procedures for backup tapes, external drives, or disaster recovery media
Frequently asked questions
When will FAQs be available?
The FAQ for this control is currently being prepared.
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