A generated chest radiograph can be useful as declared augmentation, but the same image becomes unsupported evidence when submitted as the record of a real examination. We study this problem by separating three questions: whether an image passes an automated quality check, whether an origin classifier flags it as generated, and whether a trusted record supports the claimed acquisition. In our experiments, Qwen selects up to 20 images from pools of 1,000 existing Cheff-identified or SynthCheX candidates. A receiver evaluates quality with MedGemma and predicted origin with a classifier on frozen DINOv3 features. Quality-based selection raises quality passes from 12 to 19 of 20 for Cheff-identified images and from 8 to 17 for SynthCheX. We find no evidence that selection improves passage through both checks: no selected Cheff-identified image passes both, while uniform, quality, and quality-constrained surrogate selection produce 2, 1, and 2 SynthCheX passes. On unprocessed test images, the origin classifier flags 4,677 of 5,000 SynthCheX images, but it also misclassify 110 of 2,297 NIH (real) images and 568 of 957 genuine images from another collection as fake. Our results further show that JPEG compression reduces SynthCheX-versus-NIH AUROC from 0.987 to 0.841. Even without processing, 152 SynthCheX images pass both pixel checks. These checks can filter submissions, but they cannot verify an acquisition claim. We strongly advocate that source and intended use must be recorded and checked separately for admission of chest radiographs in medical datasets.

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