Morse Fall Scale

Procedure:
Obtain a Morse Fall Scale Score by using the variables and numeric values listed
in the Morse Fall Scale table below. (Note: Each variable is given a score
and the sum of the scores is the Morse Fall Scale Score. Do not omit or change
any of the variables. se only the numeric values listed for each variable. Ma!ing
changes in this scale will result in a loss of validity. Descriptions of each
variable and hints on how to score them are "rovided below.# $he %$otal&
value obtained must be recorded in the "atient's medical record.
Morse Fall Scale
Variables Numeric Values Score
1 (istory of falling No )
*es +,
-------
! Secondary diagnosis No )
*es .,
-------
" /mbulatory aid
None0bed rest0nurse assist
1rutches0cane0wal!er
Furniture
)
.,
2) -------
# 34 or 34 /ccess No )
*es +)
-------
$ 5ait
Normal0bed rest0wheelchair
6ea!
3m"aired
)
.)
+) -------
% Mental status
Oriented to own ability
Overestimates or forgets limitations
)
., -------
Morse Fall Scale Score 7 &otal ------
Morse Fall Scale Variable Descriptions and Scorin' (ints
1 (istor) of fallin'
$his is scored as +, if the "atient has fallen during the "resent hos"ital
admission or if there was an immediate history of "hysiological falls8 such as
from sei9ures or an im"aired gait "rior to admission. 3f the "atient has not
fallen8 this is scored ). Note: 3f a "atient falls for the first time8 then his or her
score immediately increases by +,.
! Secondar) dia'nosis
htt":00www.mnhos"itals.org0inc0data0tools0Safe:from:Falls:
$ool!it0Morse-Fall-Scale-/ssessment.doc.
$his is scored as ., if more than one medical diagnosis is listed on the
"atient's chart; if not8 score ).
" *mbulator) aid
$his is scored as ) if the "atient wal!s without a wal!ing aid (even if assisted
by a nurse#8 uses a wheelchair8 or is on bed rest and does not get out of bed
at all. 3f the "atient uses crutches8 a cane8 or a wal!er8 this variable scores
.,; if the "atient ambulates clutching onto the furniture for su""ort8 score this
variable 2).
# +V or +V *ccess
$his is scored as +) if the "atient has an intravenous a""aratus or a
saline0he"arin loc! inserted; if not8 score ).
$ ,ait
$he characteristics of the three ty"es of gait are evident regardless of the
ty"e of "hysical disability or underlying cause.
.. / normal gait is characteri9ed by the "atient wal!ing with head erect8
arms swinging freely at the side8 and striding without hesitation. $his gait
scores ).
+. 6ith a wea! gait (score.)#8 the "atient is stoo"ed but is able to lift the
head while wal!ing without losing balance. 3f su""ort from furniture is
re<uired8 this is with a featherweight touch almost for reassurance8 rather
than grabbing to remain u"right. Ste"s are short and the "atient may
shuffle.
2. 6ith an im"aired gait (score +)#8 the "atient may have difficulty rising
from the chair8 attem"ting to get u" by "ushing on the arms of the chair
and0or bouncing (i.e.8 by using several attem"ts to rise#. $he "atient's
head is down8 and he or she watches the ground. =ecause the "atient's
balance is "oor8 the "atient gras"s onto the furniture8 a su""ort "erson8
or a wal!ing aid for su""ort and cannot wal! without this assistance.
Ste"s are short and the "atient shuffles.
>. 3f the "atient is in a wheelchair8 the "atient is scored according to the gait
he or she used when transferring from the wheelchair to the bed.
% Mental status
6hen using this Scale8 mental status is measured by chec!ing the "atient's
own self:assessment of his or her own ability to ambulate. /s! the "atient8
%/re you able to go to the bathroom alone or do you need assistance?& 3f the
"atient's re"ly @udging his or her own ability is consistent with the activity
order on the AardeB8 the "atient is rated as %normal& and scored ). 3f the
"atient's res"onse is not consistent with the activity order or if the "atient's
res"onse is unrealistic8 then the "atient is considered to overestimate his or
her own abilities and to be forgetful of limitations and is scored as .,.
htt":00www.mnhos"itals.org0inc0data0tools0Safe:from:Falls:
$ool!it0Morse-Fall-Scale-/ssessment.doc.