HIPAA PP-2.1: Workstation Use Policy & Implementation
Workstation use policies are foundational to HIPAA security—they define how, where, and by whom ePHI can be accessed. PP-2.1 requires you to establish clear policies covering the functions employees perform, the manner of performance, and the physical environment protecting your workstations. Without structured workstation policies, you risk unauthorized access and compliance violations.
What this means
PP-2.1 (Workstation Use) mandates that covered entities and business associates implement documented policies and procedures governing workstation access to electronic protected health information (ePHI). These policies must specify: (1) the legitimate functions that can be performed at each workstation or workstation class, (2) the procedures and best practices for performing those functions securely, and (3) the physical characteristics and environmental controls surrounding workstations that handle ePHI. This control ensures that workstations are used only for authorized purposes and that their physical and operational security matches the sensitivity of the data they process.
How to comply
- 1.Classify workstations by type and function (e.g., clinical workstations, administrative terminals, kiosks) based on the ePHI they access.
- 2.Document the authorized functions for each workstation class—specify which applications, systems, and data each workstation may access.
- 3.Create detailed procedures describing how authorized functions must be performed (login protocols, session timeouts, screen positioning, etc.).
- 4.Define physical attributes and environmental controls for each workstation (placement away from public view, monitor positioning, locking mechanisms, visitor access restrictions).
- 5.Establish policies for workstation location and placement to prevent unauthorized viewing of screens and unauthorized device access.
- 6.Implement access controls aligned with your workstation use policies (user authentication, role-based permissions, workstation-level restrictions).
- 7.Train all staff on workstation use policies and the specific rules for their assigned workstations.
- 8.Monitor and audit workstation use to ensure compliance with documented policies.
- 9.Review and update workstation policies annually or when new workstation types, systems, or locations are introduced.
Evidence auditors look for
- Workstation Use Policy document defining authorized functions, procedures, and physical attributes by workstation type
- Workstation inventory or asset register listing device locations, assigned users, and applicable policy classifications
- Physical security controls documentation (privacy screens, locking mechanisms, desk placement photos, badge access logs)
- Workstation access control logs and user authentication records demonstrating enforced policies
- Staff training records and acknowledgment forms confirming workstation use policy training
- Audit and monitoring reports showing compliance with workstation use procedures
- Incident or exception reports documenting unauthorized workstation use attempts and corrective actions
Frequently asked questions
When will FAQs be available?
The FAQ for this control is currently being prepared.
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