In addition to knowing how to interpret a chest x-ray (CXR) it’s important to understand how to appropriately document a CXR in the notes. This guide provides a structured approach to documenting chest x-rays in a patient’s notes, with included examples.
Before we discuss how to document the CXR itself, we need to cover the basics that apply to all documentation in a patient’s notes. You can check out our detailed guide to writing in the notes here for more information.
What should I use to write with?
You need to use a pen with black ink (as this is the most legible if notes are photocopied).
For every new sheet of paper your first task should always be documenting at least three key identifiers for a patient:
- Full name
- Date of birth
- Unique patient identifier
- Patient’s home address
If a patient label containing at least 3 identifiers is available then this can be used instead of writing out the information yourself.
You should also indicate the patient’s location on the continuation sheet:
Beginning your entry in the notes
At this point you should already be holding a pen with black ink and you should have ensured the continuation sheet has at least three key patient identifiers at the top.
1. Add the date and time (in 24hr format) of your entry
2. Write your name and role as an underlined heading
3. Make your entry in the notes below this heading (see the next section for details)
Documenting the CXR results in the notes
1. Document the time and date that the CXR was performed (as this may be significantly different than the time you are documenting)
2. Write the indication for the CXR (e.g. “productive cough, shortness of breath and fever ?community acquired pneumonia”)
3. Document your interpretation of the CXR (see our guide to interpreting a CXR here):
- Image quality
- Carina and bronchi
- Hilar structures
- Lung fields
- Heart size
- Heart borders
- Position / shape
- Costophrenic angles
- Everything else
- Mediastinal contours
- Tubes / valves / devices
4. Document your overall impression of the CXR (e.g. left lower lobe consolidation)
5. Document your plan based on the CXR findings
Completing the entry in the notes
At the end of your entry to need to include the following:
- Your full name
- Your grade/role (e.g. Medical student/F2/Neurology registrar)
- Your signature
- Your professional registration number (e.g. GMC number)
- Your contact number (e.g. phone/bleep)