The American Institute of Certified Public Accountants (AICPA) sets auditing standards and devised the SOC framework.
ISO 27002:2022 outlines a list of 93 controls across four themes: people, physical, technological, and organizational. These controls are recommended for a functioning information security management system (ISMS). The prior version of Annex A (or ISO 27002:2013) included 114 controls across 14 domains.
An asset is something that has value to a business. The term extends beyond physical items to include people, information, reputation, intellectual property (IP), and software.
Asset management is the process of obtaining and updating an accurate inventory of all IT assets, including the discovery of security gaps related to the asset operations and configuration. Asset management also involves enforcing security requirements to address identified security gaps.
Attestation is the end result of a SOC 2 audit. The SOC 2 report is an attestation report (not a certification). A SOC 2 auditor attests — rather than certifies — that controls have been appropriately designed.
The HIPAA Breach Notification Rule requires companies to notify patients when their PHI is impermissibly used or disclosed — or “breached.”
Business associates under HIPAA are any individual, organization, or agency (e.g., SaaS platforms, IT contractors, cloud storage, CPA firms) that performs certain functions that involve the use or disclosure of protected health information (PHI) on behalf of, or to provide services to, a covered entity.
Certification is the end result of the ISO process. It is granted by one of a handful of certifying organizations.
Clauses are a collection of shall statements that describe how to establish, run, and continually improve an information security management system (ISMS) program.
A specific procedure or protocol that is in place to address a cybersecurity risk. Controls always have an owner and an action and may have a time frame.
The activities that are undertaken by an organization to get a nonconformity back into conformance.
The number of controls mapped to each SOC 2 criteria. Auditors subjectively assess whether an organization has enough coverage.
Covered entities under HIPAA are any individual, organization, or agency that provides treatment, payment, or operations in healthcare. This includes healthcare providers (e.g., doctors, pharmacies, nurses, nursing homes, health plans (e.g., insurance companies and government plans), and healthcare clearinghouses (e.g., electronic stations that allow healthcare providers to transmit claims to insurance companies).
A certified public accountant is certified to provide accounting services in their location of licensure. Only CPAs or CPA firms can sign off on a SOC 2 report.
A cyberattack is an attempt by malicious criminals to compromise an asset by destroying, altering, or gaining unauthorized access.
Cybersecurity is the practice of protecting systems, networks, and programs from digital attacks on-line. Cybersecurity is a subset of IT Security.
Defined in HIPAA regulation as any protected health information (PHI) that is created, stored, transmitted, or received in any electronic format or media. ePHI includes any of the 18 distinct demographics that can be used to identify a patient.
The HIPAA Enforcement Rule allows the Office of Civil Rights (OCR) to investigate any violations of HIPAA, perform Privacy and Security Rule compliance audits, and issue fine penalties to those that do not comply with the rules.
Evidence is how an organization proves a control is in place or being performed. Evidence can come in many forms. The most common are system generated reports, system screenshots, change tickets, and policy and procedures documents.
Reinforcement of compliance for business associates of covered entities to HIPAA.
The Health Insurance Portability and Accountability Act of 1996 (HIPAA) is a federal law that requires the creation of national standards to protect sensitive patient health information from being disclosed without the patient's consent or knowledge.
Information or data that is of value to an organization (e.g., patient records, employees’ information, intellectual property, or company data).
Measures, procedures, processes, and technologies that businesses deploy to ensure the confidentiality, integrity, and availability of information.
A suspected, attempted, successful, or imminent threat of unauthorized access, modification, use, disclosure, or destruction of information assets. The term information security incident also refers to interference with information technology operation or violation of acceptable use policy.
A formal security program that is continuously improved upon, refined, and monitored.
An independent assessment of an organization’s information security management system (ISMS) as a whole or of any subset of controls. An internal audit is required as part of a functioning ISMS.
The International Standards Organization (ISO) is an international body that creates, maintains, and publishes frameworks that include everything from quality assurance to data privacy.
Information technology (IT) security refers to the collection of both IT and business practices that an organization puts in place to secure data. The goal is to ensure the confidentiality, availability, and integrity of company information. IT security includes overarching data handling practices, both over the web and for physical locations where data is stored.
A nonconformity is something that is not aligned with an annex control, a clause, or even a regulation or company process. Nonconformities can be identified by auditors, through incidents, by external parties, and other means.
Points of focus are areas to consider for each Trust Services Criteria. They are as close as SOC 2 gets to requirements. Think of them as hints on how to meet each criteria.
The HIPAA Privacy Rule requires appropriate safeguards to protect the privacy of protected health information (PHI) and sets limits and conditions on the uses and disclosures that may be made of such information without patient authorization. The rule also gives patients rights over their health information, including rights to examine and obtain a copy of their health records and to request corrections.
Qualified opinion is a term used by auditors to describe their opinion or conclusion about a company’s controls. A qualified opinion means the auditor liked what the company did, but with exception(s), which they explain. Qualified opinions do not mean a company failed its report and are not necessarily a bad thing, but they do indicate that the design or operation of controls did not meet the auditors’ expectations.
A section of the SOC 2 report prepared by a company’s management team. Anything in this section is fair game for an audit. Section 3 covers topics relevant to a company’s system or product, including people, processes, technology, and data that make up the environment or system that support the company’s services.
An optional section of the SOC 2 report where a company’s management team can explain any issues, test exceptions, or events that occurred subsequent to the end of the audit.
The HIPAA Security Rule is the foundation that ensures integrity, confidentiality, and security of electronic protected health information (ePHI).
Tests the design of controls as of a point in time.
Tests everything in SOC 2 Type 1 as well as the functioning or operation of controls over a period of time. The time period is typically 12 months but can be as little as three months.
An information security management system (ISMS) document required for ISO showing which Annex controls are in scope. This list is shared with auditors and assessors.
An anomaly in the design or operation of a control found by the auditor. Something to avoid, but often unavoidable.
A potential cause of an incident that may result in a breach of information security or compromise of operations.
A set of guidelines for meeting the SOC 2 standards:
When an auditor finds no issues with control design and operation, they offer an unqualified opinion. This is what all organizations strive for and indicates a clean report from the auditor.
The governing bodies of HIPAA that conduct periodic audits to ensure that covered entities and their business associates comply with the requirements of HIPAA's regulations.
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