This document evaluates an image of a stretcher chest x-ray for accuracy and quality. It analyzes the image for HIPAA compliance, proper anatomical markers, radiation safety, positioning, artifacts, sharpness, and technical exposure factors. Overall, the evaluator determines that the image meets evaluation criteria to be accepted, but could be improved by adjusting collimation and ensuring proper shoulder depression. References are also provided.

1. Image Evaluation: Stretcher Chest
Presented By:
Rochelle
Mazzella

2. HIPAA
Compliance
• This image is
HIPAA
compliant.
• Patient
identification has
been removed
from this image
• Any information
that could lead
to the institution
where the image
was take has
been removed.
• This image does
not violate the
privacy of the
patient.

3. Markers and Patient ID
• A correct anatomical
side marker visible in
the image.
• The side marker is
properly placed in this
image.
• The marker does not
superimpose anatomy.
• This image is
displayed anatomically
correct.

4. Markers and Patient ID
• Additional markers are
needed for this image
• A position marker indicates if
the patient was upright or
supine
• An up arrow marker is being
used to show that the patient
was positioned upright
• An “AP” or “PA” marker needs
to be used to show if the how
the patient was positioned for
the image
• An “AP” marker is being used in
this image to indicate that the
patient was in an AP orientation
• The image is correctly
displayed based on marker
placement.

5. Radiation Hygiene
• Beam Restriction Rule:
• A minimum of three sides of
beam restriction must be visible
on an image
• There is only one side of
collimation visible on this image.
• This does not fit minimum standards
• Beam restriction must be shown
on the side closest to the
gonads.
• Which is shown in this image
• Shielding rule:
• Gonadal shielding must be
provided if the gonads are
within five centimeters of the
primary beam.
• No evidence of secondary
shielding

6. Radiation
Hygiene
This image now shows
acceptable collimation

7. Completeness of Position/Projection
PA/AP Chest Lateral Chest

8. Completeness of
Position/Projection
• This Image does
comply with routine
position/projections
• All anatomical
parts are correctly
visualized in this
image.

9. Artifact
Identification
• There are not any
preventable physical
artifacts visible in the
image.
• There are not any
body parts
superimposed that
should not be.
• There are not any
hospital paraphernalia
present and/or visible
in the image.

10. Artifact
Identification
• There are not any
patient
clothing/belongings
visible in the image.
• There are not any
indwelling
artifacts/foreign
bodies visible in the
image.

11. Artifact Identification
• There is not excess
fog degrading image
quality.
• There are no CR/DR
artifacts.

12. Image
Sharpness
• There is not
any “gross”
voluntary
motion visible in
the image.
• There is not
any excessive
quantum mottle
(or image
noise) visible in
the image.
• There is not
any evidence of
a pervious
exposure.

13. Image Sharpness
• There are not grid lines,
grid artifact &/or grid cut-
off visible in the image
because a grid is not
typically used for a
stretcher chest.
• Size distortion does not
appear greater than
expected.
• Slight shape distortion is
being caused by poor
CR/IR/part alignment.

14. Accurate Part Positioning
• The part is adequately
aligned to the image
media.
• The part is not
adequately centered to
the image media.
• The CR is not centered
to within 1 cm of the
anatomical part.

15. Accurate Part Positioning
• The part is accurately
aligned to the
longitudinal axis of the
image.

16. Accurate Part Positioning
Optimal Alignment Acceptable Alignment

17. Accurate Part Positioning
Because this image only has one side of collimation
it does not fit optimal or acceptable alignment.

18. Accurate Part Positioning
With the newly added collimation, this
image would fit optimal alignment

19. Accurate Part Positioning
• Clean x-ray machine before
exiting patient room
• Use appropriate personal
coverings
• Cover IR with plastic bag or
pillow case
• Appropriate technical date
have been set
• Record the required data

20. Accurate Part Positioning
• Position the patient in an upright,
seated AP projection
• Center a 14x17 inch IR cassette
or digital plat CW/LW beneath
the chest to fit the body habitus
• Align the IR and midcoronal
plane parallel with the bed
• Align the front face of the
collimator parallel with the IR
• Align the CR perpendicular to the
IR
• Elevate the chin out of the
collimate field
• Depress the shoulders

21. Accurate Part Positioning
• Place the back of the hands
on the hips and rotate the
elbows and shoulders,
anteriorly if possible
• Center the CR to the MSP at a
level 4 inches inferior to the
jugular notch
• Move the arms and any
moveable lead wires outside
the collimation field
• Take the exposure after the
second full suspended
inspiration

22. Accurate Part Positioning: Evaluation
Criteria
• Evidence of proper
collimation
• Medial portion of the
clavicles equidistant
from the vertebral
column
• Trachea visible in the
midline
• Clavicles lying more
horizontal and obscuring
more of the apices than
in the PA projection

23. Accurate Part Positioning: Evaluation
Criteria
• Equal distance from the
vertebral column to the
lateral border of the ribs on
each side
• Faint image of the ribs and
thoracic vertebrae visible
through the heart shadow
• Entire lung fields, from the
apices to the costophrenic
angles
• Pleural vascular markings
visible from the hilar
regions to the periphery of
the lungs

24. Accurate Part Positioning: Evaluation
Criteria

25. Judicious Exposure Technique
• The most radiolucent
structure seen in this
image is the air in the
lungs and trachea. The
air is adequately seen
in the image.
• The most radiopaque
structure in the image
is the patient’s
stomach.

26. Judicious Exposure Technique
Assessment of Window Width
• A image of the chest
should display short
scale contrast.
• Short scale contrast is a
minimum number of
grays between black
and whites on a
radiograph.
• I think this image displays
adequate short scale
contrast.

27. Judicious Exposure Technique
Assessment of Window Level
• This image appears to
have acceptable
brightness.
• All structures are clearly
seen.
• I believe the EI value will
be in acceptable range,
but will in the lower range
of the acceptable range.

28. Accept/Reject
• This image does meet
all evaluation criteria
and does show all
anatomy needed for
the given radiograph.
• I would accept this
radiograph.

29. Accept/Reject
• To make this a more
diagnostic image:
• Adjusting the collimation
• Ensuring that there is at
least 3 sides of collimation
• Collimation should show only
anatomy of interest
• This could adjust the high
brightness seen at the
bottom of the image
• Apply secondary shielding
to the patient
• Have patient depress
shoulders more to have
clavicles lay more
horizontal

30. References
• Fauber, T. L. (2013). Radiographic Image and Exposure
(4th ed.) St. Louis, MO: Elsevier.
• Frank, E. D., Long, B. W., Smith, B. J., Merrill, V., &
Ballinger, P. W. (2007). Merrill’s Atlas of Radiographic
Positioning & Procedures. St. Louis, MO: Mosby/Elsevier.
Page 519
• McQuillen-Martensen, K. (2015). Radiographic Image
Analysis. Vol. 4. St. Louis, MO: Elsevier. Page 99