How to Document Pneumonia on Chest X-Ray
The correct spelling is "pneumonia" - spelled P-N-E-U-M-O-N-I-A - when documenting findings on chest radiography. 1
Standard Radiographic Documentation
When documenting pneumonia on chest X-ray reports, the key radiographic finding to describe is:
A new infiltrate compatible with pneumonia is the standard terminology used in radiology reports and is considered the most reliable radiographic method for diagnosing pneumonia 1
The chest radiograph should demonstrate new infiltrate(s) within 48 hours of institution of therapy to meet diagnostic criteria 1
Radiographic Terminology for Documentation
The following terms are commonly used when documenting pneumonia findings:
"Infiltrate" - the most widely accepted term for describing the radiographic appearance of pneumonia 1
"Consolidation" - used to describe more dense opacification consistent with pneumonia 1, 2
"New infiltrate compatible with pneumonia" - the complete phrase recommended in clinical practice guidelines 1
Important Documentation Considerations
Definite vs. Probable Pneumonia
Definite pneumonia requires typical diagnostic chest X-ray changes showing new infiltrates 1
Probable pneumonia can be diagnosed when clinical criteria are met but chest X-ray is negative or non-diagnostic, as radiographs may be normal early in disease (present in only 36% initially) 1, 3, 4
Key Pitfalls in Radiographic Documentation
Chest radiographs are frequently normal early in pneumonia - typical appearances are present in only 36% of initial chest X-rays 1, 4
Portable radiographs have relatively poor quality compared to standard posterior-to-anterior projections, which can affect documentation accuracy 1
Chest X-ray cannot distinguish viral from bacterial pneumonia - this should not be attempted in documentation 1, 3
27-33% of pneumonias are missed on chest X-ray but detected on CT scan, so a negative chest X-ray does not exclude pneumonia 4, 2