Chest Radiograph Reporting System: From Quality Assessment to the Impression

REPORTING SYSTEMATICS / RADIOGRAPHY

A systematic approach for PA, AP, and lateral chest radiographs that prioritizes image quality, covers blind spots, and translates into a concise report.

The first step is not to search for disease, but to assess image adequacy

Although a chest radiograph is often reviewed quickly, projection, rotation, inspiratory effort, penetration, motion, and patient position can substantially alter the appearance of findings. Technical effects such as magnification of the cardiac silhouette on a portable AP image or increased basal opacity at low lung volumes should be recognized before clinical interpretation.

The technique section does not need to list every detail, but it should clearly state limitations that affect interpretation. Particularly on intensive care and emergency department radiographs, devices, tubes, lines, and interval change from prior imaging may be central to the report.

Start with quality assessment: the RIPE approach

1. Rotation: Assess the distance between the medial clavicular heads and the spinous processes, as well as thoracic symmetry. Rotation can alter the appearance of the mediastinum and hila.
2. Inspiration: Assess lung volume, diaphragm level, and rib visibility. Inadequate inspiration may enlarge the cardiac silhouette and mimic basal opacities.
3. Projection and position: Confirm PA, AP, lateral, supine, or upright labels and markers. Projection affects apparent cardiac size and the distribution of pleural air or fluid.
4. Exposure: Check whether the mediastinal and retrocardiac regions are assessable and identify overpenetration, underpenetration, or motion artifact.

Systematic anatomic survey

After assessing quality, following the same basic sequence on every radiograph reduces blind spots:

• Airway: Is the trachea midline? Is there deviation? Are the main bronchi visible?
• Mediastinum and hila: Contours, width, hilar size and symmetry, vascular appearance, and mass effect.
• Heart and pericardium: Interpret the cardiothoracic appearance in light of the projection; assess cardiac contours and possible pericardial abnormalities.
• Lung parenchyma: Compare right and left from apices to bases; assess focal opacity, interstitial pattern, nodules, atelectasis, and vascular distribution.
• Pleura: Pneumothorax, pleural effusion, thickening, and fissures. Remember that pneumothorax may have an atypical distribution on a supine radiograph.
• Diaphragm and costophrenic angles: Height, contour, free subdiaphragmatic air, and sharpness of the angles.
• Bones and soft tissues: Ribs, clavicles, shoulder girdles, vertebrae, and visible soft tissues.
• Devices and foreign bodies: Course, tip position, and complications of endotracheal tubes, enteric tubes, central catheters, drains, pacemakers, and other devices.

Describe positive findings concisely but distinctively

Instead of writing “opacity in the right lung,” select clinically useful features such as the zone or lobe, distribution, margins, air bronchograms, signs of volume loss, and associated pleural changes. At the same time, avoid claiming excessively precise anatomic localization or etiology from a single radiograph.

When a prior radiograph is available, the direction of change is often more valuable than an isolated description. Use terms such as new, increased, decreased, or stable while accounting for projection and technical differences.

Chest radiograph report template framework

The following framework should be adapted for PA/lateral or AP radiographs:

Common mistakes

• Diagnosing cardiomegaly on a portable AP radiograph without accounting for cardiac magnification.
• Interpreting basal crowding caused by low lung volumes as infiltrate.
• Reviewing one side in detail while assessing the opposite lung only superficially.
• Overlooking the retrocardiac region and lung apices.
• Assessing pleural effusion or pneumothorax without considering patient position.
• Reporting only the tip of a tube or catheter without assessing its course for complications.
• Failing to include a new opacity from the findings section in the impression.

Prioritization in the impression

An acute finding that affects management should come first. For example, pneumothorax, a new focal airspace opacity, or malpositioned support device should be reported before chronic degenerative osseous findings. When findings are not definitive, use probabilistic language together with the image quality and clinical context.

Even when the radiograph appears normal, a measured statement such as “no acute cardiopulmonary abnormality” may be preferable to the absolute phrase “normal chest radiograph,” depending on the examination scope and indication.

Quick pre-sign-off check

Are the projection and technical adequacy correctly described? Is interval change from the prior radiograph stated? Were the apices, hila, retrocardiac region, and costophrenic angles reviewed again? Were pleural air and fluid assessed? Were device tips and courses checked? Does the first sentence of the impression communicate the most important finding?

Sources

1. ACR Practice Parameter for Communication of Diagnostic Imaging Findings (Revised 2025) — Core report components, the impression section, and principles for nonroutine communication. Source (opens in a new tab)
2. RSNA RadReport Reporting Templates — A resource for standardized, consistent, and comprehensive reporting templates. Source (opens in a new tab)
3. ESR paper on structured reporting in radiology—update 2023 — Current framework and implementation principles for structured reporting. Source (opens in a new tab)
4. Structured reporting in radiology: a systematic review — A systematic assessment of the evidence on structured reporting. Source (opens in a new tab)
5. ACR–SPR–STR Practice Parameter for the Performance of Chest Radiography — Performance and documentation of chest radiography. Source (opens in a new tab)
6. ACR–AAPM–SIIM–SPR Practice Parameter for Digital Radiography — Image information, quality, and technical principles in digital radiography. Source (opens in a new tab)