Special precautions The patient' s medical records is a legal document Comments regarding the patients behavior and attitudes should not be part of the record unless they are important from a medical or scientific standpoint a statement such as" the examination of the eyes is normal is much less accurate than the fundus is normal In the first case. it is not clear whether the examiner actually attempted to look at the fundusSpecial precautions • The patient’s medical records is a legal document • Comments regarding the patient’s behavior and attitudes should not be part of the record unless they are important from a medical or scientific standpoint • A statement such as “the examination of the eyes is normal” is much less accurate than “the fundus is normal” • In the first case, it is not clear whether the examiner actually attempted to look at the fundus