ABSTRACT Background Chest radiography is often performed preoperatively as a common diagnostic tool. However, chest radiography carries the risk of radiation exposure. Given the uncertainty surrounding the utility of preoperative chest radiographs, physicians require systematically developed recommendations. This systematic review assesses the quality and consistency of guideline recommendations for the timing and indications of preoperative chest radiography to make appropriate decisions. Methods The guideline recommendations on the management of the preoperative chest radiography, August 2024, were retrieved. All the reviewed recommendations were in English. Four reviewers independently assessed the quality of recommendations by using the Appraisal of Guidelines for Research and Evaluation–Recommendations Excellence (AGREE‐REX) instrument, which contained three main domains (clinical applicability, values and preferences, and implementability), and their reported evidence was evaluated. Results Ten eligible recommendations were included. Six and four of the recommendations were of high and moderate quality according to AGREE‐REX instrument, respectively. Overall, these guideline statements demonstrated significantly higher quality in the implementability domain (median 5.62, IQR 5.03 to 5.97), followed by the domain of value and preference (median 5.34, IQR 4.45 to 5.48) and the clinical applicability domain (median 4.96, IQR 4.27 to 5.15). Most recommendations on the preoperative chest radiograph were relatively consistent. The overall Krippendorff′s alpha value of 0.824 indicates generally satisfactory agreement and reliable ratings. Although none of the 10 recommendations advocate for routine preoperative chest radiographs, they indicate specific clinical circumstances and patient populations in which such testing may be warranted. Conclusions Routine chest radiography before surgery is generally not recommended, except in specific circumstances, as follows: (1) age > 70 years, (2) cardiac or thoracic clinical symptoms or a medical history, (3) surgery involving the chest, (4) ASA levels III to VI, and (5) work environments that may expose individuals to harmful particles. However, the final decision regarding preoperative chest radiographs should remain flexible, should be based on individual patient characteristics, the physician′s expertise, and consultation with other health‐care professionals. Clinical Trial Registration. Name of the registry: PROSPERO Unique Identifying number or registration ID: CRD42024605618 Hyperlink to your specific registration (must be publicly accessible and will be checked): https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=605618 .