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Morse Fall Scale Calculator

Created by Mariamy Chrdileli
Reviewed by Dominika Śmiałek, MD, PhD candidate and Adena Benn
Based on research by
O'Connell B, Myers H The sensitivity and specificity of the Morse Fall Scale in an acute care setting; Journal of Clinical Nursing; 2002
Last updated: Jan 18, 2024


Welcome to the Morse fall scale calculator, a convenient tool for assessing whether a patient has a risk of falling.

Identifying patients with a higher likelihood of falling can be crucial in avoiding fall-related injuries. Our Morse fall risk scale calculator can not only determine fall risk in patients but assist in choosing appropriate interventions and observing the progression of balance and gait over time. Come along if you wish to know:

  • What the Morse fall scale is;
  • What is the secondary diagnosis on the Morse fall scale;
  • How to interpret the Morse fall score; and
  • How the Morse Fall Scale calculator works.

❗ Note that the More fall scale calculator is meant to be used by medical professionals only. If you're struggling with unsteady or staggering gait, and it's hard to maintain your balance, please consult a physician.

What is the Morse fall scale?

The Morse fall scale is a fast and reliable method for evaluating a patient's fall risk. The scale consists of six items:

  • A history of falling;
  • The presence of secondary diagnosis;
  • A patient's ability to walk unsupported;
  • The presence of intravenous therapy or heparin lock;
  • A patient's gait; and
  • Mental status.

Staff nurses can administer the assessment in acute and long-term care inpatient settings, though interpretations of the results may vary according to the particular healthcare settings.

How to administer the Morse fall scale

When using the Morse fall scale calculator, you can consider the item descriptions and evaluation hints below:

  1. History of falling (immediate or within 3 months) explores whether the patient has experienced a fall during or before the hospital admission, including falling from seizures or impaired mobility and gait.
  2. Secondary diagnosis requires you to check the patient's chart to establish whether the patient has a secondary diagnosis (i.e., more than one active medical diagnosis).
  3. Ambulatory aid evaluates whether:
    • The patient can walk safely unsupported without a walking aid, with the assistance of a nurse, needs a wheelchair for mobility, or is on bed rest;
    • The patient needs crutches, a cane, or a walker; or
    • The patient uses clutching onto the furniture for support.
  4. Intravenous therapy/heparin lock explores whether the patient uses intravenous therapy or saline/heparin lock.
  5. Gait" explores whether:
    • The patient has a normal gait, i.e., the patient can either walk with an upright body posture with hands swinging and striding as expected, uses a wheelchair, or is currently on bed rest.
    • The patient has a weak gait, i.e., the patient does not have an upright body posture but still maintains the head lifted when walking, has impaired stride-to-stride control, and may grab onto furniture occasionally.
    • The patient has an impaired gait, i.e., the patient can not keep his head upright, has difficulty getting up from the chair or needs several tries, and cannot walk without the assistance of furniture or a nurse.
  6. Mental status explores how accurately the patient estimates their mobile capabilities. To assess this variable, you can ask the patient to perform a particular activity; for instance, you can ask whether they can walk to the washroom independently or need assistance. If their mobility is congruent with their response (i.e., they can perform the activity mentioned), you can choose oriented to own ability. If they cannot, and their response is unrealistic, select "Overestimates/Forgets limitations".

Keep reading to find out how to interpret the Morse fall scale score.

🔎 If you're working with elderly patients, you may also enjoy the Omni BIMS calculator, a handy tool for assessing cognitive impairment.

How to interpret the Morse fall risk scale score?

You can find the interpretations of the Morse fall scale calculator's scores in the table below:

Score

Interpretation

Recommendation

0 – 24

Low fall risk

Implement low-risk fall prevention interventions

25 – 45

Medium fall risk

Implement medium-risk fall prevention interventions

Above 45

High fall risk

Implement high-risk fall prevention interventions

How does the Morse fall risk scale calculator work?

Using the Morse fall risk scale calculator is quite simple; all you have to do is carefully evaluate your patient on each item of the scale utilizing the scoring hints given above.

In the end, the tool will compute whether your patient has low, moderate, or high fall risk and provide recommendations regarding the intervention the patient should receive.

If you think the Morse fall scale calculator is helpful, we have more handy tools! Use the Barthel index calculator for assessing daily self-care and mobility and our Tinetti calculator for examining balance and gait.

FAQ

What is the secondary diagnosis on the Morse fall scale?

The secondary diagnosis on the Morse Fall Scale assesses whether the patient has more than one active medical diagnosis. If the patient has only one active medical diagnosis, the item "Secondary diagnosis" should be scored as 0.

How do I score the Morse fall risk scale?

To score the Morse Fall Risk Scale, you need to:

  1. Evaluate the patient on each assessment item (e.g., if the patient does not have a history of falling, you would score them 0);
  2. Compute the sum of the scores to see which category your patent's score fits (i.e., whether the patient has low, moderate, or high fall risk).

What does a score of 45 mean on the Morse fall scale?

A score of 45 on the Morse fall risk scale means the patient has moderate (bordering on high) fall risk. Healthcare professionals recommend activating standard fall prevention interventions for patients with this score. Note that patients with a score above 45 have a high fall risk.

What are similar assessment tools as the Morse fall scale?

Several assessment tools address fall risk and balance abilities; some of them include:

  • Performance-oriented mobility scale (the Tinetti test) – A widely used task-oriented observational test of gait, balance, and fall risk.
  • The Berg balance scale – An objective measure of functional balance assessing sitting, standing, and dynamic balance. The scale displays high reliability and validity in elderly individuals and various patient populations, including those with acute stroke and Parkinson's.

Who can administer the Morse fall scale?

The Morse fall scale is a simple method to assess a patient's fall risk and can be administered by staff nurses. The scale consists of six items and is relatively easy to score.

Mariamy Chrdileli
Instructions: Assess the patient's fall risk using the items presented below. If you're unsure regarding any of the variables, please find the detailed descriptions in the "How to administer the Morse fall scale" section of the article.
History of falling (immediate or previous)
No
Secondary diagnosis (2 or more medical diagnoses in chart)
No
Ambulatory aid
None / Bed rest / Nurse assist
Intravenous therapy/Heparin lock
No
Gait
Normal / Bed rest / Wheelchair
Mental status
Oriented to own ability
Fall risk score
0
According to the score of 0 points, the patient has low fall risk. It is recommended for this patient to receive fall prevention interventions specifically designed for someone with low fall risk.
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