Data Access and Compliance Audit Logging Policy (SEC-POL-011)

1. Objective

The objective of this policy is to establish comprehensive audit logging requirements for data access, modification, and regulatory compliance activities within [Company Name]’s information systems. This policy ensures that access to electronic Protected Health Information (ePHI), sensitive data, and compliance-related activities are comprehensively captured, monitored, and analyzed to support regulatory compliance, data protection, and forensic analysis. This policy focuses specifically on data handling, privacy protection, and compliance reporting while coordinating with authentication and network logging requirements defined in SEC-POL-010.

2. Scope

This policy applies to all [Company Name] information systems, applications, databases, and services that process, store, or transmit sensitive data, ePHI, or compliance-related information. This includes all production databases, data processing applications, data analytics platforms, backup systems, and data transmission services across all environments. All workforce members, contractors, and third parties with access to sensitive data are subject to the data access and compliance logging requirements defined in this policy.

3. Policy

• [Company Name] shall implement comprehensive audit logging and monitoring capabilities for all data access, modification, and compliance activities to ensure regulatory compliance, data protection, and forensic analysis capabilities as defined in SEC-POL-009 and coordinated with authentication and network logging requirements in SEC-POL-010.

3.1 Data Access and Modification Logging

All systems processing sensitive data shall generate detailed audit logs for data-related security events to provide comprehensive accountability and support regulatory compliance.

3.1.1 Data Access Event Logging

The following data access and modification events shall be logged by all applicable systems:

• Electronic Protected Health Information (ePHI) Access:
  • All access to ePHI including read, view, print, and export activities with patient identifier correlation
  • ePHI query activities including database searches, report generation, and data analytics operations
  • ePHI modification events including create, update, delete, and merge operations with before/after values where feasible
  • ePHI transmission activities including email, file transfer, API calls, and system-to-system communications
  • Bulk ePHI operations including batch processing, data migration, and system integration activities
  • ePHI backup and recovery operations including data restoration and archive access
• Sensitive Data Handling Events:
  • Access to personally identifiable information (PII), financial data, and other classified data categories
  • Data classification and labeling activities including sensitivity assessment and protection application
  • Data encryption and decryption activities with key usage tracking and access justification
  • Data sharing and collaboration activities including external partner access and third-party data processing
  • Data retention and disposal activities including automated purging and manual data destruction
  • Data loss prevention (DLP) policy violations and data leakage prevention actions
• Database and Application Data Events:
  • Database query execution including SELECT, INSERT, UPDATE, and DELETE operations with query details
  • Stored procedure and function executions with parameter values and execution results
  • Database schema modifications including table alterations, index changes, and permission modifications
  • Application-level data access including user interface interactions and API-based data operations
  • Data export and import operations including file downloads, uploads, and bulk data transfers
  • Data synchronization and replication activities including cross-system data consistency operations

3.1.2 Data Event Log Content Standards

All data access audit log entries shall contain the following minimum information:

• Data Context and Classification:
  • Data classification level (Public, Internal, Confidential, Restricted, ePHI) and handling requirements
  • Specific data elements or fields accessed with field-level granularity where technically feasible
  • Patient identifiers or subject identifiers for ePHI and PII access tracking
  • Data volume or record count for bulk operations and batch processing activities
  • Data retention requirements and regulatory classification affecting the accessed information
  • Business justification or workflow context for data access activities
• Access Details and Metadata:
  • User identification with role, department, and business justification for data access
  • Application or system component facilitating the data access with version and configuration information
  • SQL queries, API calls, or specific operations performed on the data
  • Success or failure status with detailed error codes and data validation results
  • Data transformation or processing activities performed during access
  • Integration with authentication events from SEC-POL-010 through session correlation identifiers

3.2 Compliance and Regulatory Logging

Comprehensive compliance logging shall capture activities required for regulatory compliance and audit support.

3.2.1 HIPAA Compliance Logging

• HIPAA Security Rule Compliance Events:
  • Administrative safeguards implementation including security officer activities and workforce training records
  • Physical safeguards validation including facility access controls and workstation security measures
  • Technical safeguards operation including access controls, audit controls, and transmission security
  • Risk assessment and security incident activities related to ePHI protection and breach prevention
  • Business associate agreement compliance monitoring including third-party access and data processing activities
  • Minimum necessary rule compliance tracking including access justification and data minimization activities
• HIPAA Privacy Rule Compliance Events:
  • Patient consent and authorization activities including consent capture, modification, and withdrawal
  • Notice of Privacy Practices distribution and acknowledgment tracking
  • Patient rights exercised including access requests, amendment requests, and accounting of disclosures
  • Uses and disclosures of ePHI including purpose, recipient, and authorization basis
  • Complaints and privacy-related inquiries including investigation and resolution activities
  • Marketing and fundraising communications including opt-out preferences and consent management

3.2.2 SOC 2 and Industry Compliance Logging

• SOC 2 Trust Services Criteria Compliance:
  • Security controls operation including logical access, system monitoring, and change management activities
  • Availability controls validation including system monitoring, backup operations, and disaster recovery testing
  • Confidentiality controls implementation including data classification, encryption, and access restrictions
  • Processing integrity controls including system monitoring, data validation, and error handling
  • Privacy controls operation including notice, choice, access, and accountability requirements
• Industry-Specific Compliance Events:
  • HITRUST CSF control implementation and validation activities including assessment preparation and remediation tracking
  • Payment Card Industry (PCI) compliance activities if applicable including cardholder data protection and network security
  • State privacy law compliance including CCPA, GDPR, and other applicable privacy regulations
  • Industry-specific reporting requirements including regulatory submissions and compliance certifications
  • Third-party audit and assessment activities including external auditor access and evidence provision

3.3 Data Protection and Privacy Logging

Comprehensive data protection logging shall ensure privacy controls and data handling compliance.

3.3.1 Privacy Controls Logging

• Data Subject Rights Management:
  • Data subject access requests including request receipt, processing, and fulfillment activities
  • Right to rectification requests including data correction and validation procedures
  • Right to erasure (right to be forgotten) requests including data deletion and verification procedures
  • Data portability requests including data extraction and format conversion activities
  • Consent management activities including consent capture, withdrawal, and preference management
  • Privacy preference and opt-out management including marketing communications and data processing restrictions
• Data Processing and Transfer Events:
  • Cross-border data transfers including adequacy determinations and safeguard implementations
  • Data processing purpose changes including notice provision and consent management
  • Third-party data sharing activities including data sharing agreements and purpose limitations
  • Data minimization activities including automated data reduction and retention policy enforcement
  • Pseudonymization and anonymization activities including privacy-enhancing technology implementation
  • Data breach detection and notification activities including breach assessment and regulatory reporting

3.3.2 Data Lifecycle Management Logging

• Data Retention and Disposal:
  • Automated data retention policy enforcement including retention schedule application and data aging
  • Data disposal activities including secure deletion, media destruction, and disposal certification
  • Legal hold implementation including litigation hold application and data preservation
  • Archive and backup data management including long-term storage and retrieval activities
  • Data migration and system decommissioning activities including data transfer and legacy system retirement
  • Data quality and integrity validation including data validation, cleansing, and error correction

3.4 Compliance Monitoring and Reporting

Data access and compliance logs shall be continuously monitored and analyzed to ensure regulatory compliance and data protection.

3.4.1 Real-Time Compliance Monitoring

• Automated Compliance Monitoring:
  • 24/7 automated monitoring of ePHI access patterns and policy compliance
  • Real-time detection of data access policy violations and unauthorized data handling
  • Automated correlation of data access events with authentication activities from SEC-POL-010
  • Behavioral analysis for unusual data access patterns including bulk downloads and off-hours access
  • Integration with data loss prevention (DLP) systems for real-time data protection
  • Automated response capabilities for high-risk data access scenarios
• Compliance Alert Management:
  • Severity-based compliance alert classification (Critical, High, Medium, Low) with automated escalation
  • Real-time alerting for ePHI access violations and privacy rule breaches
  • Automated notification for data subject rights requests and regulatory compliance deadlines
  • Integration with incident response procedures for compliance violations
  • Automated reporting to Privacy Officer and Compliance Team for regulatory events

3.4.2 Compliance Reporting and Analytics

• Regulatory Compliance Reporting:
  • Automated generation of HIPAA compliance reports including ePHI access summaries and security incident reports
  • SOC 2 compliance evidence collection including control operation documentation and exception reporting
  • HITRUST CSF assessment support including control evidence and implementation documentation
  • Privacy regulation compliance reporting including data processing activities and data subject rights fulfillment
  • Breach notification support including incident documentation and regulatory filing assistance
• Data Analytics and Insights:
  • ePHI access pattern analysis including user behavior analytics and anomaly detection
  • Data processing trend analysis including volume patterns and compliance metrics
  • Privacy rights request analysis including request patterns and fulfillment metrics
  • Compliance program effectiveness measurement including policy violation trends and remediation success
  • Executive dashboard with key compliance metrics and regulatory status indicators

3.4.3 Data Access and Compliance Monitoring Implementation

• Cloud-Native Data Analytics and Compliance:
  • AWS CloudTrail data events for S3 bucket access with automated ePHI access pattern analysis and compliance monitoring
  • AWS CloudWatch for database activity monitoring with automated detection of unusual data access patterns and bulk operations
  • Azure SQL Database auditing for ePHI access tracking with automated compliance reporting and privacy controls monitoring
  • Google Cloud Audit Logs for BigQuery and Cloud SQL with automated data access analysis and regulatory compliance validation
  • Cross-cloud data access correlation with standardized compliance event classification and automated regulatory reporting
• Database Activity Monitoring (DAM) and Data Security:
  • Real-time database activity monitoring for all ePHI and sensitive data access with automated policy enforcement and compliance validation
  • Automated SQL query analysis for data access pattern detection including bulk operations, unusual queries, and privilege escalation attempts
  • Database security policy enforcement including access controls, encryption validation, and data masking compliance
  • Integration with data loss prevention (DLP) systems for real-time data protection and compliance monitoring
  • Automated evidence collection for SOC 2 and HIPAA audits including data access reports and control operation documentation
• Privacy and Compliance Management Integration:
  • Automated HIPAA compliance monitoring including ePHI access tracking, minimum necessary rule compliance, and business associate oversight
  • Privacy rights management including automated data subject request processing, consent management, and privacy preference enforcement
  • Regulatory reporting automation including breach notification assistance, compliance reporting, and audit evidence collection
  • Integration with privacy management platforms including OneTrust, TrustArc, or similar solutions for comprehensive privacy program management
  • Automated compliance dashboard including key performance indicators, regulatory deadlines, and compliance status tracking

3.5 Integration with Authentication and Network Logging

This policy coordinates with SEC-POL-010 (Authentication and Network Audit Logging Policy) to ensure comprehensive security and compliance coverage.

3.5.1 Cross-Policy Coordination

• Event Correlation and Integration:
  • Data access events shall include session identifiers for correlation with authentication events from SEC-POL-010
  • Database connections and API calls shall be correlated with network communication logs from SEC-POL-010
  • User data access patterns shall be analyzed in context of authentication behavior and network activity
  • Compliance violations shall trigger coordinated review of authentication, network, and data access logs
  • Incident response procedures shall integrate evidence from both authentication/network and data access domains
• Shared Infrastructure and Standards:
  • Common log management infrastructure shared with SEC-POL-010 for centralized analysis and correlation
  • Consistent log format standards and retention policies coordinated between authentication, network, and data logging
  • Integrated monitoring and alerting platforms combining authentication, network, and data access security events
  • Unified incident response procedures incorporating evidence from all logging domains
  • Coordinated compliance reporting combining authentication controls with data protection requirements

3.6 Incident Response and Forensics Support

Data access and compliance logs shall provide comprehensive support for security incident investigation and regulatory compliance validation.

3.6.1 Data Breach Investigation Support

• Breach Detection and Analysis:
  • Automated detection of potential data breaches through data access pattern analysis
  • Evidence collection for breach notification requirements including affected data identification and access timeline reconstruction
  • Integration with breach response procedures including impact assessment and notification requirements
  • Forensic analysis capabilities for data access incidents including timeline reconstruction and evidence preservation
  • Coordination with legal and compliance teams for breach response and regulatory notification
• Compliance Investigation Support:
  • Rapid search and analysis capabilities for compliance investigations and audit support
  • Evidence collection for regulatory inquiries including data access documentation and control operation evidence
  • Timeline reconstruction for compliance violations including user activity and system behavior analysis
  • Integration with legal hold procedures for litigation and regulatory investigation support
  • Chain of custody procedures for compliance-related evidence and audit documentation

4. Standards Compliance

See Annex: Control Mapping

5. Definitions

See Annex: Glossary

6. Responsibilities

Role	Responsibility
Privacy Officer	Overall responsibility for data access and compliance audit logging program and coordination with SEC-POL-010 requirements.
Data Protection Team	Implementation and management of data access logging systems, privacy controls monitoring, and compliance event analysis.
Database Administrators	Configuration of database activity monitoring, data access logging, and maintenance of data logging infrastructure.
Compliance Team	Regular audit of data access and compliance logging practices, regulatory reporting, and audit evidence collection.
Security Operations Center (SOC)	24/7 monitoring of data access security events, compliance violations, and privacy-related incident escalation.
Incident Response Team	Utilization of data access logs for breach investigation, evidence collection, and regulatory notification support.
Legal Team	Legal hold procedures, regulatory compliance guidance, and coordination with privacy and data protection requirements.
All Workforce Members	Compliance with data access and privacy logging policies and prompt reporting of suspected data security events.