Definition of Variables for the Morse Scale

History of falling
Yes (scored 25) if a previous fall is recorded during the present admission or if there is immediate history of physiological falls (i.e., from seizures, impaired gait) prior to admission.

Secondary diagnosis
Yes (15) if more than one medical diagnosis is listed on the patient chart.

Ambulatory aids
Scored 0 if patient walks without a walking aid even if assisted by a nurse or is on bedrest.
Scored 15 if ambulatory with crutches, cane, or walker.
Scored 20 if clutches for support.

Intravenous therapy
Scored 20 if has an IV apparatus or heparin lock.

Gait
Normal gait scored 0 if patient is able to walk with head erect, arms swinging freely at the side, & strides unhesitantly.

Weak gait scored 10 if patient is stooped but able to lift head while walking. Furniture support may be sought but is of feather-weight touch, almost for reassurance. Steps are short, and the patient may shuffle.

Impaired gait scored 20 if patient is stooped, may have difficulty rising from the chair, attempts to rise by pushing on the arms of the chair and/or by "bouncing". The patient's head is down, and because balance is poor the patient grasps the furniture, a person, or walking aid for support and cannot walk without assistance. Steps are short and patient shuffles. If patient is wheelchair-bound, the patient is scored according to the gait used when transferring from the wheelchair to the bed.

Mental Status
The patient is asked if s/he is able to go to the bathroom alone or if she/he is permitted up. If the patient's response is consistent with the ambulatory orders on the Kardex, the score is 0.
If the response is not consistent with the orders or if the patient's assessment is unrealistic, score is 15.

High risk is a score of 45 and above. The patient's actual score should be charted as well as ranking of risk (high medium and low).
 

Posted with permission from: Morse JM, Morse RM, Tylko, SJ. Development of a scale to identify the fall-prone patient. Canadian Journal on Aging. 8 (4): 366-367, 1989. http://www.utpjournals.com/jour.ihtml?lp=cja/cja.html