BACKGROUND The preoperative evaluation is designed to identify factors that may predispose a patient to perioperative complications in an effort to ensure patient safety. The use of chest radiography in the preoperative evaluation has progressed from routine testing to a more selective approach based on evidence that routine testing is low yield. However, preoperative chest radiography (POCR) may still be utilized more frequently than necessary as guidelines provide varying recommendations and providers continue to order the test by convention. The literature is reviewed to update providers on the indications for POCR and encourage more selective use. METHODS Articles related to POCR were retrieved via PubMed search and subsequent cited reference search. Effort was made to analyze primarily meta-analysis, systematic reviews and current guidelines and secondarily larger observational studies. No randomized controlled trials related to use of POCR were identified. RESULTS POCR frequently detects abnormalities; however, a majority of abnormalities detected are in patients with a history of cardiopulmonary disease or signs and symptoms indicative of cardiopulmonary disease. The frequency with which detected abnormalities influence perioperative management is low and evidence suggests that the clinical examination alone provides sufficient information to dictate any necessary changes in management in a majority of cases. Current evidence does not support the ability of POCR to reliably predict postoperative pulmonary complications. CONCLUSIONS Selective use of POCR is recommended. Emphasis on a thorough preoperative clinical examination is usually sufficient to make decisions on perioperative management as POCR rarely provides significant additional information. POCR is generally indicated in patients with signs or symptoms of acute or unstable cardiopulmonary disease. The relationship between POCR and patient outcomes, morbidity and mortality is not known.