# Assess a possible HIPAA breach and decide on notifications

Walks through the four-factor breach risk assessment, documents the decision, and drafts the notifications required if it is a reportable breach.

- Topic: Legal & Compliance
- Framework: Few-Shot
- Level: Advanced
- Tags: Legal, Analyze, Fill-in Template
- Source: https://www.thinkwithprompt.com/prompts/assess-a-possible-hipaa-breach-and-decide-on-notifications

## Prompt

```text
Help me assess a possible privacy incident at our practice.

**What happened:** [e.g. "a lab result was faxed to the wrong number", "a laptop was stolen from a car", "a staff member viewed a neighbor's chart"]
**Date it happened and date we discovered it:** [DATES]
**Information involved:** [types - names, DOB, SSN, diagnoses, insurance IDs, images]
**Number of individuals affected:** [NUMBER]
**Who received or accessed it:** [e.g. another provider, unknown person, an employee]
**Mitigation so far:** [e.g. recipient attested destruction, device was encrypted, access revoked]
**State(s) where affected patients live:** [STATES]

Do this:
1. Check whether an exception applies (unintentional good-faith access by staff, inadvertent disclosure between authorized people, recipient could not retain the information) or whether the data was secured (encrypted to the HHS standard).
2. If not, walk through the four-factor risk assessment: nature and extent of the PHI, the unauthorized person, whether the PHI was actually acquired or viewed, and the extent of mitigation. Give a reasoned conclusion: low probability of compromise or presumed breach.
3. If it is a breach, list the notifications and deadlines: individuals (without unreasonable delay, no later than 60 days from discovery), HHS (within 60 days of discovery if 500 or more; if fewer, log it and report within 60 days after the end of the calendar year), prominent media outlets if more than 500 residents of one state are affected, plus any state law notices to [CONFIRM].
4. Draft the individual notice letter with the required elements, using placeholders.
5. A one-page incident documentation record and corrective actions (training, sanctions per policy, process change).

This is general information, not legal advice. Have the conclusion reviewed by our privacy officer and healthcare counsel before acting.
```

## What to fill in

- DATES
- types - names, DOB, SSN, diagnoses, insurance IDs, images
- NUMBER
- e.g. another provider, unknown person, an employee
- STATES
- CONFIRM

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