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Workstation Use: Workstation use rules for shared clinical machines

March 5, 2026 · Ken Armstrong

Auditors ask about workstation use early, because the answer tells them how the rest of the program is likely to look. The requirement is 45 CFR 164.310(b).

What the rule says

Standard: Workstation use. Implement policies and procedures that specify the proper functions to be performed, the manner in which those functions are to be performed, and the physical attributes of the surroundings of a specific workstation or class of workstation that can access electronic protected health information.

That is the text of 45 CFR 164.310(b). Read it closely: it describes an outcome to achieve, not a product to buy, which is why two practices of the same size can satisfy it in different ways and both be right.

This is a standard, and a standard is met in full: 45 CFR 164.306(c) requires a covered entity or business associate to comply with the applicable standards.

What this looks like in practice

In an assessment, 45 CFR 164.310(b) is not one question. It resolves into several, and each one is really asking for different evidence. These are among the questions asked about it:

Does the organization require workforce members to lock or obscure screens, and secure electronic media, that can display or hold ePHI when a workstation is left unattended?
Does the organization require workforce members who handle sensitive data from remote or non-office locations to apply physical safeguards protecting that data from unauthorized view and access?
Has the organization established and communicated rules for the acceptable use and handling of ePHI and of the workstations and devices that access it?

Ownership usually sits with whoever controls building access, though the evidence is often produced by someone else, which is where the trail breaks. A control that works but has no owner tends to stop working the month the person who quietly maintained it changes roles.

Who this applies to

Every covered entity and every business associate, at any size. 45 CFR 164.306(b) allows flexibility of approach, so a two-provider practice and a hospital system may implement this differently and both comply. What flexibility does not allow is skipping the decision: the smaller the organization, the more the written reasoning carries the weight, because there is no scale of operation to make the control self-evident.

Building it, in order

These steps are one way to meet it, drawn from our question bank. Unless a step names a provision, the Security Rule does not require that particular measure: 45 CFR 164.306(b)(1) lets you use any security measures that allow you to reasonably and appropriately implement the standards and implementation specifications, chosen with the factors in 45 CFR 164.306(b)(2).

The sequence below is the order that produces evidence as a by-product rather than as a separate documentation exercise:

Establish a policy requiring screens that display ePHI to be locked or obscured, and electronic media holding ePHI to be secured, when a workstation is left unattended.
Enforce an automatic session lock after a short period of inactivity.
Apply the policy to onsite and remote workstations.
Communicate the requirements to all workforce members and reinforce them periodically.
Record how the measure chosen meets the cited provision. 45 CFR 164.306(b)(1) lets the organization use any security measures that allow it to reasonably and appropriately implement the standards and implementation specifications, and the Security Rule does not name this practice. The cited standard and any Required implementation specification must be met. An Addressable one must be implemented, or the organization documents why it is not reasonable and appropriate and implements an equivalent alternative measure if that is reasonable and appropriate (45 CFR 164.306(d)(3)). Choose the measure with the factors in 45 CFR 164.306(b)(2) and document it with the risk analysis.
Require remote workforce members to handle sensitive data in a private space where unauthorized individuals cannot see or overhear.

Where else this maps

The questions behind 45 CFR 164.310(b) also map to NIST SP 800-66 Rev. 2 5.2.2, 5.2.3, which is voluntary guidance rather than law; following it does not by itself establish compliance with any law. That matters for scoping: the same evidence can be written once and referenced from each, rather than rewritten per framework.

Evidence an assessor asks for

For this requirement the evidence type that satisfies it is a policy. The distinction matters more than it looks: a policy states what you intend to do, a procedure states how, and a record proves it happened on a date. Auditors ask for all three, and a practice that has written the first two often has nothing for the third.

Date every document and keep the superseded versions. 45 CFR 164.316(b)(2)(i) requires the documentation 164.316(b)(1) calls for (the Security Rule policies and procedures, and the written record of any action, activity or assessment the Security Rule requires to be documented) to be retained for six years from the date of its creation or the date when it last was in effect, whichever is later, so a policy you replaced two years ago is still part of the record.

Where this usually goes wrong

The usual gap is a control that exists in practice and nowhere in writing. Someone does the work, reliably, and it has never been written down, so the organization cannot demonstrate it and cannot notice when it stops. The fix is not more control, it is a dated record and a named owner.

What to do about it

Produce the evidence, not the intention. For 45 CFR 164.310(b) that means a signed, dated policy with a named owner and a review date. If the only evidence is that someone knows how this works, you have a practice and not a record.
Put a name on it. Whoever controls building access should be recorded as the owner. Where the work is done by someone else, say so in the document: the split between who owns it and who performs it is where the trail usually breaks. A control with no owner stops working the month the person who quietly maintained it changes roles, and nobody notices.
Set a review cadence and keep the evidence of each review. An annual date with a dated output is a common floor; what fails an assessment is a control implemented once and never re-checked against a changed environment.
There is no documented-alternative route for the requirement itself. It is required (45 CFR 164.306(d)(2) for a specification, 164.306(c) for a standard), so a risk-based decision not to meet it is not available. How you meet it is yours to choose under 45 CFR 164.306(b); the measures in this post are examples, not the rule's text.

The practical test for 45 CFR 164.310(b) is whether someone unfamiliar with your organization could read your documentation and tell what you do, who does it, and when it last happened. If they can, the documentation will hold up; whether the requirement is met is a judgment about what it shows, and your counsel owns that conclusion. If they need you in the room to explain it, it will not.

Related requirements

References

45 CFR 164.310(b), in 45 CFR 164.310 on eCFR. Quoted text verified against the eCFR text current as of 2026-10-06.
The Required and Addressable designations are defined at 45 CFR 164.306(d).
Crosswalk references in this post are the mappings in our question bank, and are not verified against the published text of those standards.
This post describes what a requirement asks for and what evidence documents it. It is not legal advice, and your counsel owns the conclusion. State law may impose additional obligations; HIPAA preempts a State law only where it is contrary to HIPAA (45 CFR 160.202, 160.203).