American College of Radiology

View all recommendations from this society

Released April 4, 2012; updated June 29, 2017

Avoid admission or preoperative chest x-rays for ambulatory patients with unremarkable history and physical exam.

Performing routine admission or preoperative chest x-rays is not recommended for ambulatory patients without specific reasons suggested by the history and/or physical examination findings. Only 2 percent of such images lead to a change in management. Obtaining a chest radiograph is reasonable if acute cardiopulmonary disease is suspected or there is a history of chronic stable cardiopulmonary disease in a patient older than age 70 who has not had chest radiography within six months.

These items are provided solely for informational purposes and are not intended as a substitute for consultation with a medical professional. Patients with any specific questions about the items on this list or their individual situation should consult their physician.

How The List Was Created

(1-5) The American College of Radiology (ACR) initially solicited expert opinion from physician leaders with its Board of Chancellors. A working group was then formed to further identify common clinical scenarios in which imaging may be misused and should be reconsidered. Members of the group included the physician chairs or vice chairs of seven ACR commissions such as Quality and Safety, Appropriateness Criteria and Metrics. An initial list of topics was narrowed down based on the highest potential for improvement, representing a broad range of tests and the availability of strong guidelines. Members then researched specific recommendations and evidentiary statements based on their expertise. Recommendations that were too general or were well covered by other existing measures and initiatives were eliminated to identify the final five things list.

(6-10) The Choosing Wisely initiative was presented to the organization’s physician leaders at a Board of Chancellors meeting and a working group selected five initial low-value imaging targets for reduced utilization. The second set of targets was created by the following working group, with the goals of minimizing unnecessary imaging and biopsy generated by discovery of incidental findings, improving patient safety through reduced radiation exposure, and reducing unnecessary consultations based on imaging findings.

  • Pamela T. Johnson, MD, Chair, Choosing Wisely Recommendations
  • Jacqueline A. Bello, MD, FACR, Chair of Commission on Quality and Safety
  • Mythreyi B. Chatfield, PhD, Executive Vice President for Quality and Safety
  • Jonathan Flug, MD, MBA, Quality Management Committee
  • Jenny K. Hoang, MBBS, lead author on ACR White Paper for Managing Incidental Thyroid Nodules
  • Alec J. Megibow, MD, MPH, FACR, Committee on Economics – Body Imaging Commission
  • Pari V. Pandharipande, MD, MPH, Chair of Committee on Incidental Findings
  • Saurabh Rohatgi, MD, Committee on Quality Experience – Commission on Patient and Family Centered Care

Research: For the topics related to incidental findings on imaging exams, the American College of Radiology has created evidence-based white papers to provide guidance to practicing radiologists on making management recommendations. The white paper publications and additional relevant literature serve as the evidence supporting those recommendations. For the remaining recommendations pertaining to body CT protocol design, published literature was reviewed to define acceptable indications for multiphase protocols.

ACR’s disclosure and conflict of interest policy can be found at


McComb, BL, Chung, JH, Crabtree, TD, Heitkamp, DE, Iannettoni, MD, Jokerst, C, Saleh, AG, Shah, RD, Steiner, RM, Mohammed, TLH, Ravenel, JG, Expert Panel on Thoracic Imaging. ACR Appropriateness Criteria® Routine Chest Radiography. [Online Publication]. Reston (VA) American College of Radiology (ACR); 2015. Available at:

Gomez-Gil E, Trilla A, Corbella B, et al. Lack of clinical relevance of routine chest radiography in acute psychiatric admissions. Gen Hosp Psychiatry 2002; 24(2):110-113.

Archer C, Levy AR, McGregor M. Value of routine preoperative chest x-rays: a meta-analysis. Can J Anaesth 1993;40(11):1022-1027.

Munro J, Booth A, Nicholl J. Routine preoperative testing: a systematic review of the evidence. Health Technol Assess 1997;1(12):i-iv; 1-62.

Grier DJ, Watson LF, Harnell GG, Wilde P. Are routine chest radiographs prior to angiography of any value? Clin Radiol 1993;48(2):131-33.

Gupta SD, Gibbins FJ, Sen I. Routine chest radiography in the elderly. Age Ageing. 1985;14(1):11-14.

American College of Radiology. ACR Appropriateness Criteria: routine chest radiographs in ICU patients

Suh, RD, Genshaft, SJ, Kirsch, J, Kanne, JP, Chung, JH, Donnelly, EF, Ginsburg, ME, Heitkamp, DE, Henry, TS, Kazerooni, EA, Ketai, LH, McComb, BL, Ravenel, JG, Saleh, AG, Shah, RD, Steiner, RM, Mohammed, TLH, Expert Panel on Thoracic Imaging. ACR Appropriateness Criteria® Intensive Care Unit Patients. [Online Publication]. Reston (VA) American College of Radiology (ACR); 2014. Available at: