Clinical Documentation

Morse Fall Risk Scale

The Morse Fall Scale (MFS) is a rapid and simple method of determining a patient's likelihood of falling. A large majority of nurses (82.9%) rate the scale as "quick and easy to use," and 54% estimated that it took less than 3 minutes to rate a patient. The MFS consists of six variables that are quick and easy to score, and it has been shown to have predictive validity and interrater reliability. The MFS is used widely in acute care, hospital, rehabiliation and nursing homes.

Scoring and Risk Level: The MFS score is tallied and recorded on the patient's chart. Risk level and appropriate interventions are then identified. The six variables are:

  • History of falling; immediate or within 3 months
  • Secondary diagnosis is present
  • Ambulatory aid
  • IV/Heparin Lock
  • Gait
  • Mental status

MFS scores range from 0 to 125:

  • 0-24: Low risk
  • 25-45: Moderate risk
  • 46+: High risk