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Morse Fall Scale

Fall Risk Assessment in Hospitalised Patients

Fall in the last 3 months or during the current admission

More than one medical diagnosis recorded in the notes

Aid used by the patient when mobilising

Patient with peripheral or central venous access with continuous or intermittent infusion

Gait pattern observed during ambulation

Patient's perception of their own ability to mobilise safely

Interpretation

Score Classification Action
0 – 24 No risk / Low risk Basic nursing care
25 – 50 Moderate risk Implement standard fall prevention plan
≥ 51 High risk Implement high fall risk protocol

Note: The Morse Fall Scale was developed and validated for adult patients in acute hospital settings. It should be applied on admission and reassessed periodically, or whenever there is a change in the patient's clinical status, in accordance with institutional protocol. It is a screening instrument and does not replace the clinical judgement of the healthcare professional.

References

  • 1. Morse JM, Morse RM, Tylko SJ. Development of a scale to identify the fall-prone patient. Can J Aging. 1989;8(4):366–377. PubMed ↗
  • 2. Morse JM, Black C, Oberle K, Donahue P. A prospective study to identify the fall-prone patient. Soc Sci Med. 1989;28(1):81–86. PubMed ↗
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