This Morse fall scale calculator aims to screen fall risk in all hospitalized patients and recommends the initiation of fall prevention procedures where adequate. There is more information on the risk factors involved in this fall screening tool available below the form.
How does this Morse fall scale calculator work?
This health tool evaluates the risk of falling in hospitalized patients based on certain patient status related variables.
This six question test is defined as a simple and rapid risk stratification method with a total time duration to administer of less than 5 minutes.
This fall risk scale can be used in the clinical setting as well as in long term care inpatient settings and is usually administered by nurses.
Subsequent validation studies have revealed a high interrater reliability.
The Morse fall scale calculator consists in the following 6 patient parameters:
- History of falling (immediate or previous) – looks at whether the patient has already had an episode of falling during the current admission or has an immediate history of falls, either caused by gait or seizures.
- Secondary diagnosis (2 or more medical diagnoses in chart) – evaluates the existence of other comorbidities.
- Ambulatory aid – checks whether the patient is using a walking aid, either being helped or through a crutches, cane or wheelchair. Also consider any possible disabilities.
- Intravenous therapy/ heparin lock – checks the existence of initiated IV medication.
- Gait – evaluates the presentation of the patient and their balance status. Weak gait is defined as short steps, the patient in a stooped state but able to lift head, seeking support from furniture while walking but just for reassurance. Impaired gait is defined as short steps with shuffle, head down, difficult arising from chair, impaired balance or needing walking aid.
- Mental status – evaluated through the ability of the patient to assess their own condition and the consistency of their answers.
Once the risk factors are highlighted and the medical professional has an idea about the risk category the patient is in, they can devise a care plan oriented toward prevention.
The test is often administered in conjunction with other assessment methods such as a clinical exam and a review of the current medication.
One of the criticisms received by the method consists in the genericity of the six variables assessed and the fact that different medical settings might present with different risk factors and challenges for the patient’s care. Therefore the assessor needs to consider local circumstances in the overall result as well.
Morse scale scoring system
The six items in the score are awarded a different number of points depending on how much the respective risk factor can weigh on the overall result.
1. History of falling (immediate or previous):
■ Yes (25 points)
■ No (0 points)
2. Secondary diagnosis (2 or more medical diagnoses in chart):
■ Yes (0 points)
■ No (15 points)
3. Ambulatory aid:
■ None/ bed rest/ nurse assist (0 points)
■ Crutches/ cane/ walker (15 points)
■ Furniture (30 points)
4. Intravenous therapy/ heparin lock:
■ Yes (0 points)
■ No (20 points)
■ Normal/ bed rest/ wheelchair (0 points)
■ Weak (10 points)
■ Impaired (20 points)
6. Mental status:
■ Oriented to own ability (0 points)
■ Overestimates/ forgets limitations (15 points)
Once the whole score is totaled, the result will then be an indication of one of the three risk categories below:
■ <25: low fall risk;
■ 25 – 45: moderate fall risk;
■ >45: high fall risk.
Each of the categories has a different set of recommendations, from preventive intervention in order to avoid any trauma occurring to implementation of standard procedures follower by permanent monitoring.
In the cases of patients deemed low risk, the advice is to continue with basic nursing care, in patients with moderate risk, the standard fall prevention interventions should be activated while in patients with high risk, the high risk fall prevention intervention should prevail.
1) Morse JM, Morse RM, Tylko SJ. (1989) Development of a scale to identify the fall-prone patient. Can J Aging; 8:366-7.
2) O'Connell B, Myers H. (2002) . J Clin Nurs; 11(1):134-6.
3) Oliver D, Daly F, Martin FC, McMurdo ME. (2004) . Age Ageing; 33(2):122-30.
4) Schwendimann R, De Geest S, Milisen K. . Oxford Journals Medicine & Health Age and Ageing; Volume 35, Issue 3Pp. 311-313.06 Feb, 2016 | 0 comments