Consistent, current and complete documentation in the medical record is an essential component of quality patient care. Failure to properly document a patient encounter can lead to significant liability issues for healthcare providers. Careful documentation in the patient’s record improves the provider-patient relationship, enhances reimbursement and is a leading factor in determining whether a plaintiff’s attorney will pursue a potential claim of medical malpractice. With the enactment of the 21st Century Cures Act, patients now have easy access to their medical record. While this empowers patients to be more engaged in their healthcare decision making, it also creates greater accountability for care providers.