Morse Fall Risk Scale Reprinted with permission from Morse, J. M. (2009). Preventing patient falls: Establishing a fall intervention program. New York: Springer Publishing Company. All rights reserved. Documented by: Documented at: days hours minutes after Score: _____ Does the patient have a recent history of falling: ○ Yes (25) Patient has fallen at any point during this admission or there is immediate history of falls (e.g., from seizures or impaired gate prior to admission) ○ No (0) Patient has not fallen recently Score: _____ Does the patient have secondary medical diagnoses? ○ Yes (15) ○ No (0) Score: _____ Are ambulatory aids used? ○ Bed rest/nurse assist (0) Patient walks without a walking aid (even if assisted by a nurse), uses a wheelchair, or is on bed rest and does not get out of bed at all ○ Uses crutches/cane/walker (15) Patient uses crutches, a cane, or a walker ○ Uses furniture (30) Patient walks clutching onto furniture for support Score: _____ Does the patient have an intravenous apparatus, or a heparin lock inserted? ○ Yes (20) ○ No (0) Score: _____ What is the patient’s gait? ○ Normal/bed rest/immobile (0) Patient walks with head erect, arms swinging freely at the side, and striding without hesitation ○ Weak (10) Patient is stooped but is able to lift the head while walking and does not lose balance; steps are short, and the patient may shuffle ○ Impaired (20) Patient’s head is down, and he or she watches the ground; because the patient’s balance is poor, the patient grasps onto the furniture, a support person, or a walking aid for support and cannot walk without this assistance; patient may have difficulty rising from a chair, attempting to get up by pushing on the arms of the chair or by bouncing (i.e., taking several attempts to rise) Score: _____ What is the patient’s mental status (related to ambulatory abilities)? Determine the patient’s own self-assessment of his/her ability to walk. You may ask the patient, “Are you able to go to the bathroom alone or do you need assistance?” ○ Normal/oriented to own ability (0) Patient’s reply judging his or her own ability to walk is consistent with the ambulatory order ○ Forgets limitations (15) Patient’s response is not consistent with the nursing orders or the patient’s response seems unrealistic; patient is considered to overestimate his or her abilities and limitations Morse Fall Risk Total Score: _____ High Risk (51 or Higher) Moderate Risk (25-50) Low Risk (0-24) Recommended Actions: Notes:
