How to Define Morse Score

Health care workers in hospitals and in nursing homes and other long-term-care inpatient settings use the Morse Fall Scale, or MFS, to estimate patients' likelihood of falling down so they can take preventive measures. The scale is made up of six variables that are easy to score. Health care workers assess patients using the scale when patients are admitted to the facility, every day during the day shift, when patients' conditions change, when they go on medications that might put them at risk, when patients are transferred, and after a fall.

Things You'll Need

• Morse Fall Scale

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Instructions

Six Variables

• 1

  Determine the patient's history of falling, the first variable on the Morse Fall Scale. Give a score of 25 to patients who are limping from having fallen recently or who fall during admission, and to patients who fall for the first time. Assign a 0 to patients who have not fallen.

• 2

  Determine the patient's secondary diagnosis. Give a score of 15 to patients who have more than one diagnosis listed on their charts. Give a 0 to patients who have a 0 on their histories and who have just one medical diagnosis listed on their charts.

• 3

  Determine the patient's ambulatory aid. Give a 15 to patients who use crutches, canes or walkers, and a 30 to patients who grab onto furniture for support. Patients who don't require walking aids (such as canes), or who use wheelchairs or never get out of bed, receive a score of 0.

• 4

  Note whether the patient is using an intravenous tube. Give a 20 to patients who have an IV, and a 0 to patients who don't.

• 5

  Determine the patient's gait: normal, weak or impaired. Normal gait means patients walk with proper posture and without hesitation, and those patients get a score of 0. A weak gait means patients are stooped over but can lift their heads without losing their balance; this carries a score of 10. Impaired gait means patients walk with their heads down and have poor balance that requires them to use walking aids; they score 20.

• 6

  Determine the patient's mental status. Ask your patients whether they need help walking. Give a 0 to patients who say they don't need help and show no trouble walking. Give a 15 to patients who say they don't need help but who have trouble walking.

Determining Fall Risk Level

• 7

  Use the Fall Risk Level table to review the MFS scores and determine whether patients have a low, medium or high risk of falling down, and what preventive action to take.

• 8

  Administer basic nursing care for patients who are at no or low risk or who score between 0 and 24 on the MFS.

• 9

  Implement standard fall-prevention measures for patients who are at medium risk or who score between 25 and 44.

• 10

  Implement high-risk fall-prevention measures for patients who are at high risk or who score a 51 or greater.