Skip to main content
HIPAA Path
Category: HITRUST CSF and Scoring

Illustrative Procedures

Also known as: Illustrative Audit Procedures, Example Procedures
Simply put

Illustrative procedures are example steps that a practitioner (such as an auditor or examiner) can look at as a model when planning the work they will perform in an engagement. They are meant to guide and illustrate, not to serve as a fixed checklist that must be followed exactly. In practice, the actual procedures a practitioner performs are tailored to the specific engagement, subject matter, and applicable professional standards.

Formal definition

In an attestation or audit context, illustrative procedures are non-authoritative examples provided in professional guidance to help practitioners interpret and apply attestation standards when performing examination, review, or agreed-upon procedures engagements. As reflected in AICPA guidance materials, they demonstrate the types of procedures that might be appropriate for a given subject matter but are not prescriptive; the practitioner is generally expected to exercise professional judgment and adapt or supplement them to fit the specific engagement circumstances and the governing standards (for example, the agreed-upon procedures framework described in AT Section 201). This term relates to audit and attestation practice and is out of scope for the HIPAA regulatory framework; illustrative procedures do not themselves establish or substitute for compliance with the HIPAA Privacy Rule, Security Rule, or any HITRUST CSF control requirement. Readers evaluating compliance-related engagements should verify the applicable procedures against the current professional standards and, where relevant, current regulatory guidance.

Why it matters

Illustrative procedures matter because they give practitioners a concrete starting point when planning an attestation or audit engagement, reducing the risk that important considerations are overlooked while still preserving the flexibility that professional judgment requires. In healthcare compliance work, where an organization may commission an examination or agreed-upon procedures engagement related to its safeguards, understanding that these procedures are examples rather than a mandatory checklist helps set accurate expectations about what an engagement will and will not cover.

A common source of confusion is the assumption that following a set of illustrative procedures automatically demonstrates compliance with a regulatory or control framework. It does not. Illustrative procedures are non-authoritative guidance drawn from professional attestation standards, and they exist to help practitioners interpret and apply those standards. They do not establish, and cannot substitute for, compliance with the HIPAA Privacy Rule, the HIPAA Security Rule, or any HITRUST CSF control requirement. Treating example procedures as a compliance guarantee can lead organizations to overstate the assurance an engagement provides.

Because the actual procedures performed must be tailored to the specific engagement, subject matter, and governing standards, stakeholders relying on an engagement report should understand what procedures were actually performed rather than assuming the illustrative examples were applied verbatim. Readers evaluating compliance-related engagements should confirm the applicable procedures against the current professional standards and, where relevant, current regulatory guidance.

Who it's relevant to

Auditors and Attestation Practitioners
Practitioners performing examination, review, or agreed-upon procedures engagements use illustrative procedures as a planning aid, adapting them through professional judgment to the specific subject matter and applicable attestation standards rather than following them as a fixed checklist.
Compliance and Privacy/Security Officers
Officers who commission or rely on attestation engagements benefit from understanding that illustrative procedures are examples, not guarantees. An engagement built around them does not by itself establish HIPAA or HITRUST CSF compliance, so officers should focus on which procedures were actually performed and what assurance the report provides.
Legal and Contract Professionals
Those drafting or reviewing engagement terms and reliance provisions should recognize that the value of an engagement depends on the procedures actually agreed and performed. Illustrative procedures inform planning but do not define the scope of assurance and should not be represented as evidence of regulatory compliance.
Organizational Leadership Relying on Reports
Executives and boards receiving attestation results should understand that illustrative procedures are non-authoritative examples and that any compliance-related conclusions must be verified against current professional standards and, where relevant, current regulatory guidance from HHS OCR or the applicable HITRUST CSF version.

Inside Illustrative Procedures

Definition and Purpose
Illustrative procedures are example testing or audit steps that demonstrate how an assessor or practitioner might evaluate whether a control or safeguard is implemented and operating as intended. They are meant to guide and inform, not to serve as a mandatory checklist prescribed by the regulation itself.
Non-Prescriptive Nature
Because the HIPAA Security Rule is generally designed to be technology-neutral and scalable, illustrative procedures typically offer suggested approaches rather than required steps. Actual procedures should be tailored to the entity's size, complexity, and risk environment.
Relationship to Safeguard Categories
Illustrative procedures may be organized around the Security Rule's administrative, physical, and technical safeguard categories, and can address both required and addressable implementation specifications. Note that addressable specifications are not optional and still require evaluation.
Use in Assessment Frameworks
Frameworks such as the HITRUST CSF may present illustrative procedures to help assessors test controls. HITRUST is a private organization, and its CSF is a certifiable control framework; the presence of illustrative procedures within it does not by itself establish HIPAA compliance.
Evidence Orientation
Illustrative procedures generally point toward the types of evidence a practitioner might gather, such as reviewing policies, interviewing personnel, or inspecting configurations, to support a conclusion about a control's design and operating effectiveness.

Common questions

Answers to the questions practitioners most commonly ask about Illustrative Procedures.

Are illustrative procedures mandatory steps that must be followed exactly to achieve HIPAA compliance?
No. Illustrative procedures are examples or reference approaches, not prescriptive mandates. The HIPAA Security Rule generally allows covered entities and business associates flexibility in how they implement safeguards, taking into account their size, complexity, and risk environment. Following an illustrative procedure verbatim does not by itself guarantee compliance, and deviating from one does not automatically indicate a violation. Organizations should tailor their actual procedures to the results of their own risk analysis and verify their approach against the current regulatory text.
Does completing the illustrative procedures associated with a HITRUST CSF control establish HIPAA compliance?
No. HITRUST is a private organization and the HITRUST CSF is a certifiable control framework; neither is a legal requirement. Illustrative procedures within a control framework may help demonstrate how a control is implemented and tested, but performing them does not by itself establish compliance with HIPAA, which is a federal law enforced by HHS OCR. HITRUST certification and HIPAA compliance are distinct, and readers should not treat one as a substitute for the other. Confirm control mappings against the current HITRUST CSF version and the applicable regulation.
How should an organization use illustrative procedures when building its own control testing program?
Illustrative procedures are typically used as a starting reference for how a control might be examined or evidenced. In most cases, an organization adapts them to its specific systems, data flows, and risk profile rather than adopting them wholesale. It is generally advisable to document how each adapted procedure ties back to the safeguard or requirement it is intended to address, and to note any scope differences between the illustrative example and the organization's actual environment.
What kind of evidence do illustrative procedures generally help an organization gather?
Illustrative procedures typically describe how one might confirm that a control is in place and operating, which in turn suggests the types of evidence to collect, such as policies, configuration records, logs, or interview results. The specific evidence needed depends on the control and the environment. Because the Security Rule addresses only electronic protected health information while the Privacy Rule covers PHI in all forms, organizations should be clear about which rule and which data a given procedure supports.
How do required versus addressable implementation specifications affect the use of illustrative procedures?
For required specifications, an illustrative procedure generally points toward confirming the safeguard is implemented as specified. For addressable specifications, the procedure may need to reflect an organization's documented decision, whether it implemented the specification, adopted an equivalent alternative, or determined it was not reasonable and appropriate. Addressable does not mean optional, so illustrative procedures for addressable items should typically account for documenting the rationale behind the chosen approach.
Who within an organization typically applies illustrative procedures, and what should they verify first?
In most cases, privacy officers, security officers, internal auditors, or compliance staff apply illustrative procedures, sometimes alongside external assessors. Before relying on any illustrative procedure, they should generally verify that it maps to the correct HIPAA rule and safeguard category (administrative, physical, or technical), confirm it reflects the current regulatory text or current HITRUST CSF version, and consider whether state law or the HITECH Act imposes additional requirements beyond what the procedure addresses.

Common misconceptions

Following the illustrative procedures exactly guarantees HIPAA compliance.
Illustrative procedures are examples, not a compliance guarantee. HIPAA compliance is determined by whether an entity meets the applicable requirements of the relevant rules, and no single set of testing steps ensures compliance or prevents all breaches. Readers should assess their own risk environment and verify against current regulatory guidance.
Illustrative procedures are mandated by the HIPAA regulations.
The Security Rule is generally scalable and technology-neutral and does not typically prescribe specific step-by-step procedures. Illustrative procedures are supplied by assessment frameworks or practitioner guidance, not by the CFR text itself, and should be tailored to the organization.
Because a specification is addressable, its illustrative procedures can be skipped.
Addressable does not mean optional. Entities must still evaluate addressable implementation specifications and document their decisions, so illustrative procedures for addressable items remain relevant to the assessment.

Best practices

Treat illustrative procedures as a starting point and tailor them to your organization's size, complexity, and documented risk analysis rather than adopting them verbatim.
Map each procedure to the correct safeguard category (administrative, physical, or technical) and clearly track whether the underlying specification is required or addressable, remembering that addressable still requires action or documented justification.
Gather and retain supporting evidence, such as policies, interview notes, and configuration reviews, to substantiate conclusions rather than relying on the procedure text alone.
Distinguish HIPAA obligations from HITRUST CSF illustrative procedures, and do not treat completion of framework procedures or certification as equivalent to establishing HIPAA compliance.
Document the rationale where you modify, add, or omit a procedure, so the assessment approach is defensible and traceable.
Verify any specific requirements, penalty references, or citations against the current regulatory text and the current HITRUST CSF version, and consider whether state law or the HITECH Act imposes additional requirements.