Morse Fall Scale

Bedside fall-risk screen for adult acute-care inpatients, summing six items to stratify fall risk and activate fall-prevention measures.

History of falling (within 3 months, or this admission)

0 - No 25 - Yes

Secondary diagnosis (more than one medical diagnosis)

0 - No 15 - Yes

Ambulatory aid

0 - None / bed rest / nurse-assisted 15 - Crutches, cane, or walker 30 - Furniture (uses furniture for support)

IV therapy or saline / heparin lock

0 - No 20 - Yes

Gait / transferring

0 - Normal / bed rest / wheelchair / immobile 10 - Weak (= stooped but can lift head, short steps, may shuffle) 20 - Impaired (= short steps with shuffle, head down, may require assistance, cannot walk without help)

Mental status

0 - Oriented to own ability 15 - Forgets limitations / overestimates own ability