Morse Fall Scale
Inpatient fall risk.
Inputs
CompleteHistory of falling (immediate or within 3 months)
Secondary diagnosis (more than one medical diagnosis)
Ambulatory aid
IV therapy or saline lock
Gait
Mental status
Worked calculation
Your values are highlighted.
- Points
When to use
- On admission, after a fall, and with a change in condition.
Pearls and pitfalls
- Thresholds are commonly 25 (moderate) and 45 (high); calibrate to your unit.
Why use
Standard nursing fall-risk tool.
| Criterion | Points |
|---|---|
| History of falling (immediate or within 3 months) | +25 |
| Secondary diagnosis (more than one medical diagnosis) | +15 |
| Ambulatory aid: None, bed rest, or nurse assist | 0 |
| Crutches, cane, or walker | +15 |
| Furniture | +30 |
| IV therapy or saline lock | +20 |
| Gait: Normal, bed rest, or wheelchair | 0 |
| Weak | +10 |
| Impaired | +20 |
| Mental status: Oriented to own ability | 0 |
| Overestimates or forgets limitations | +15 |