Wound Bed Assessment with TIME Framework

Inspection template for documenting wound bed status using the TIME framework: tissue, infection/inflammation, moisture, and wound edge condition, to support wound bed preparation planning and follow-up.

Assessment Scope and Wound Identification

• Wound location and laterality documented
  Record the anatomical location, side, and any wound identifier used in the chart.
• Wound type or etiology documented
  Identify the likely wound type or cause to support appropriate wound bed preparation.
• Wound measurements recorded
  Document length, width, and depth, and note undermining or tunneling if present.
• Photo evidence captured when policy allows
  Attach a wound photo if permitted by facility policy and consent requirements.
• Assessment date and time recorded
  Capture when the wound bed assessment was completed.

T - Tissue

• Predominant wound bed tissue identified
  Select all tissue types present in the wound bed.
• Viable tissue percentage estimated
  Estimate the approximate percentage of viable tissue in the wound bed.
• Nonviable tissue burden documented
  Rate the amount of slough, eschar, or necrotic tissue present.
• Debridement need or tissue management plan noted
  Document whether debridement is indicated or whether current tissue management is appropriate.
• Signs of stalled healing related to tissue status documented
  Note whether tissue appearance suggests delayed healing or need for escalation.

I - Infection / Inflammation

• Local infection signs assessed
  Select all local signs present, such as erythema, warmth, swelling, pain, purulence, or malodor.
• Systemic infection indicators reviewed
  Assess for fever, chills, tachycardia, or other systemic concerns requiring escalation.
• Drainage characteristics documented
  Record drainage amount and character as part of infection surveillance.
• Infection concern escalated when indicated
  Confirm whether provider notification, culture, or other escalation was completed when infection was suspected.
• Antimicrobial or infection-control plan documented
  Document any topical antimicrobial use, culture plan, or infection-control follow-up.

M - Moisture

• Wound moisture balance assessed
  Rate whether the wound bed is too dry, balanced, or excessively moist.
• Periwound maceration or desiccation noted
  Select any moisture-related periwound findings.
• Drainage amount documented
  Document the amount of exudate to guide dressing selection and moisture management.
• Moisture management plan documented
  Document dressing choice, absorbency, barrier protection, or hydration strategy as appropriate.
• Moisture-related complication requires intervention
  Indicate whether moisture imbalance is causing deterioration or requires escalation.

E - Edge and Periwound

• Wound edge condition assessed
  Select all edge findings present.
• Periwound skin condition documented
  Document surrounding skin findings such as erythema, fragility, induration, or intact skin.
• Edge management or offloading plan documented
  Document interventions such as offloading, edge protection, or referral for advanced wound care.
• Need for escalation due to wound edge deterioration
  Indicate whether wound edge findings require provider review or wound specialist referral.