Morse Fall Scale: Inpatient Fall Risk Screening

The Morse Fall Scale scores six items with unequal weights: history of falling within three months, presence of a secondary diagnosis, use of an ambulatory aid, intravenous therapy or a saline lock, gait, and mental status meaning whether the person's self-assessment of their own mobility is accurate. The weights reflect how strongly each predicted falls in the original derivation rather than clinical importance.

It was built for speed and for use by any nurse on admission, and it is repeated after a fall, on transfer between units and on a change in condition. Two design points are worth understanding. The mental status item is not a cognitive test: it asks whether the patient's belief about their ability to move safely matches reality, and overestimation is the risk. And the intravenous therapy item is a proxy for tethering to equipment rather than a statement about the drug.