Morse_Fall_Scale_guideline v.1
An assessment used to predict the risk of falling based on personal fall history, mental status, and other risk factors.
To predict the risk of falling based on personal fall history, mental status, and other risk factors.
The tool consists of 6 fall risk parameters: - History of falling looks at whether the patient had an episode of falling during the current stay or has a history of falls, regardless of their cause (for example, gait type or seizures): Yes (25), No (0) - If the patient has a secondary diagnosis, meaning 2 or more diagnoses in the patient chart, the risk of fall increases: Yes (0), No (15) - Ambulatory aid refers to the patient making use of walking aid (cane, crutches or wheelchair): None/ bed rest/ nurse assist (0), Crutches/ cane/ walker (15), Furniture (30) - Intravenous therapy/ heparin lock checks whether the patient is under IV medication: Yes (0), No (20) - The Gait item evaluates the patient’s balance status: Normal/ bed rest/ wheelchair (0), Weak (10), Impaired (20) - Mental status is assessed through the consistency of the patient’s answers: Oriented to own ability (0), Overestimates/ forgets limitations (15) Morse score Fall risk Recommendation Below 25 Low Continue with basic nursing care 25 - 45 Moderate Activate standard fall prevention intervention Above 45 High Ensure fall prevention is in place and is effective
Morse, Janice M., Robert M. Morse, and Suzanne J. Tylko. Development of a scale to identify the fall-prone patient. Canadian Journal on Aging/La Revue canadienne du vieillissement 8.4 (1989): 366-377. O'Connell B, Myers H. The sensitivity and specificity of the Morse Fall Scale in an acute care setting. J Clin Nurs. 2002 Jan;11(1):134-6. doi: 10.1046/j.1365-2702.2002.00578.x. PMID: 11845750.
openEHR-EHR-OBSERVATION.morse_fall, openEHR-EHR-EVALUATION.morse_fall_assessment
