The Morse Fall Scale is a quick nursing score of how likely a patient is to fall in hospital. Six items, from a history of falling to mental status, add up to a total from 0 to 125, and a higher score means a higher risk. See what each risk level means and which precautions follow, then record the result with the free template. Score it on the official form.
Morse Fall Scale result template
FreeMORSE FALL SCALE RESULT Date and time: [Date, time] Patient: [Name or ID, age] Unit: [Medical, surgical, day surgery, rehab, or long-term care] Reason for scoring: [Admission, routine reassessment, after a fall, transfer, change in condition, or before discharge] Scored by: [Name, credentials] ITEMS History of falling: [Finding, and its score on the form] Secondary diagnosis: [Finding, and its score on the form] Ambulatory aid: [What the patient walks with, and its score on the form] IV or heparin lock: [Access in place or not, and its score on the form] Gait: [What you saw as the patient rose and walked, and its score on the form] Mental status: [What the patient says they can do, what you saw, and its score on the form] TOTAL AND RISK LEVEL Total: [0 to 125] Risk level: [Low, moderate, or high, and the cutoffs the unit uses] Last score: [Date and total, or first score this stay] Not counted by the scale: [Sedatives or opioids, anticoagulant, diuretic or urgency, dizziness on standing, nerve block, low vision, or none] INTERVENTIONS IN PLACE Bed: [Low and locked, floor mat, rails as policy sets] Call bell and belongings: [In reach, and whether the patient can use the bell] Footwear: [Nonslip socks or own shoes] Toileting: [Schedule, bedside commode, or staff stay during toileting] Alarm: [Bed or chair alarm on, or not needed] Supervision: [Standard checks, hourly rounding, room near the station, sitter, or video monitoring] Walking: [Aid within reach, help needed, physical therapy referral] Fall risk sign: [Wristband, door sign, or flag in the record, as policy sets] EDUCATION Patient: [What was taught, and the teach-back result] Family: [Who was taught, and what] REASSESSMENT Next score: [Next shift, date, or the change that will trigger it] Reported to: [Charge nurse, provider, pharmacist, or physical therapist, and when] Signed: [Name, credentials, date and time]
Use it for
A nurse scores it at the bedside, from the chart, from asking the patient, and from watching them stand and walk. It takes a minute or two on the unit’s form.
Avoid: Scoring gait and mental status from the last shift’s note. Both change quickly with pain, sedation, or delirium.
History of falling, secondary diagnosis, ambulatory aid, IV or heparin lock, gait, and mental status, added for a total from 0 to 125.
Avoid: Adding points for things the form doesn’t score, such as age or medicines. Note them beside the score instead.
A higher total means a higher risk. Most units call 0 to 24 low, 25 to 44 moderate, and 45 or more high; follow your unit’s cutoffs.
Avoid: Reading a low score as no risk. The scale can’t predict a sudden faint or seizure, or a trip over a cord.
The risk level sets the precautions, and they go in the same note as the score.
Avoid: Raising all four bed rails to keep a confused patient in bed. They may climb over and fall from higher, and most policies count full rails as a restraint.
Score again at the interval your unit sets, and whenever the patient’s risk may have changed.
Each one follows the recording template. Use them to judge how much to write.
Medical unit, admission from the emergency department, evening shift
81-year-old man admitted with a urinary tract infection and new confusion. History of falling: yes, fell in his kitchen 3 days ago, which is why his daughter brought him in. Secondary diagnosis: yes, urinary tract infection, heart failure, and atrial fibrillation. Ambulatory aid: walker, at home and on the unit. IV or heparin lock: saline lock in the left forearm for IV ceftriaxone. Gait: stooped, with short steps behind the walker; stands in one try using the chair arms. Mental status: says he doesn’t need the walker to get to the bathroom, and left it behind twice in the emergency department.
Total 100, high risk by the unit’s cutoff of 45. First score this admission. Not counted by the scale: apixaban, so a fall could mean a serious bleed; furosemide each morning, with urgency; confusion worse at night. No sedatives ordered.
Moved to a room two doors from the nursing station. Bed low and locked, with a floor mat on the exit side. Call bell clipped to his gown; he can press it but can’t be relied on to. Nonslip socks on. Toileting every 2 hours while awake and before sleep, with staff staying with him. Bed alarm on. Hourly rounding; sitter to be requested if he keeps getting up alone. Walker at the bedside, 1 assist for all walking. Saline lock capped between doses, so there’s no tubing to trip on. Glasses on and a night light on. Fall risk wristband and door sign, as policy sets.
Patient: asked to ring before getting up; he repeated it back but had forgotten within the hour, so the plan relies on the alarm and rounding. Daughter: walked through the precautions, asked to call staff rather than help him up herself, and to bring his hearing aids tomorrow. She’ll stay in the evenings this week.
Every shift, and at once after any fall, any change in his confusion, or when the saline lock comes out. Reported to the charge nurse and the admitting physician at 21:40; delirium workup, a pharmacist medicine review, and physical therapy requested.
Day surgery unit, second-stage recovery, before discharge
45-year-old woman after a right knee arthroscopy under general anesthesia. History of falling: no. Secondary diagnosis: no; the torn meniscus is her only diagnosis. Ambulatory aid: crutches for the first few days, weight-bearing as tolerated. IV or heparin lock: IV removed at 13:15, before her first walk. Gait: upright and steady on the crutches with even steps; rose from the chair without help. Mental status: alert and oriented; knew to wait for the nurse the first time she stood, and did.
Total 15, low risk. Admission score before surgery: 0. Not counted by the scale: oxycodone 5 mg at 12:40 for pain, now 2 out of 10 with no drowsiness. No nerve block. No dizziness sitting or standing; blood pressure 118/72 standing.
Standard precautions: recliner and bed low and locked, call bell in reach, her own sneakers on, a clear path to the bathroom. First walk with the nurse beside her. Crutch practice on the flat and on 4 stairs: up with the good leg first, down with the crutches first.
Patient: crutch use, getting in and out of the car, rugs moved and a clear path at home, and a shower chair for the first few days; she taught it back. Husband: drives her home and stays overnight; shown how to steady her on the stairs.
No further score on this unit; discharge criteria met, and she went home at 14:30. Told to call the unit or her surgeon after a fall, or with new numbness, dizziness, or calf pain. Surgeon aware.
Gait and mental status need the patient in front of you. A score taken from the chart misses the patient who stands up dizzy or forgets their walker.
The Morse doesn’t count medicines, sedation, or a nerve block. A patient who scores 15 an hour after an opioid still needs a nurse beside them the first time they stand.
A total of 70 with only basic care in place leaves the risk where it was. Name the interventions in the same note as the score.
The admission score misses the patient who has since had surgery, started a sedative, or become confused. Score again after any change, and after any fall.
Adding items or changing the points makes it a local tool, not the Morse Fall Scale, and the published cutoffs no longer apply. Set your unit’s cutoffs instead, as Morse advises.
Vero Scribe records the Morse result in your template from the visit, with the patient’s consent, or from your dictation: the six items, the total, the risk level, and the precautions in place. You review and edit every line, then copy it into your record. Vero works in 60+ languages.
Score each of the six items on the official form: history of falling, secondary diagnosis, ambulatory aid, IV or heparin lock, gait, and mental status. The form gives the points for each finding. Add them for a total from 0 to 125. It takes a minute or two at the bedside.
A higher total means a higher risk of falling. The most widely used levels are 0 to 24 low risk, 25 to 44 moderate risk, and 45 to 125 high risk. Each level comes with its own precautions, from basic safety measures to an alarm and close supervision.
45 or more, on the most widely used cutoffs. Another common set calls 0 to 24 no risk, 25 to 50 low risk, and 51 or more high risk. Morse advises each unit to set its cutoffs for its own patients, so follow your organization’s policy and record which cutoffs you used.
On admission, after any fall, on transfer to another unit, and whenever the patient’s condition changes, such as after surgery, sedation, or new confusion. Many hospitals also score it every shift or every day; your policy sets the interval.
The Hendrich II Fall Risk Model and the Johns Hopkins Fall Risk Assessment Tool are other hospital scores. Both count medicines, which the Morse doesn’t, and the Hendrich II includes a test of rising from a chair. For older adults living at home, clinicians use a fuller fall risk assessment with timed tests, such as the Timed Up and Go, instead.
Nurses usually score it, on admission and at each reassessment, and your organization’s policy sets who may. Short training with the published scoring instructions helps different nurses give the same patient the same score.
It was developed for adults in hospital. Pediatric units use tools built for children, such as the Humpty Dumpty Falls Scale.
ePROVIDE, a catalog of clinical outcome measures, lists no copyright holder for it. The scale and its scoring were published by Dr. Janice Morse and colleagues and in her book Preventing Patient Falls, and many hospitals build it into their records. Get the official form from that source or through ePROVIDE’s free sign-up, and ask before reproducing or changing it. The recording template on this page is free to copy or download.
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For older adults living at home: falls history, timed gait tests, medicines, and a plan to change the causes.
The full nursing assessment, with the Morse score and precautions in the safety section.
Nursing progress notes, DAR examples, SBAR handoffs, and patient teaching records.
Every tool, by area, with what its scores mean.
Vero records scores, findings, and plans in the templates you choose, so you review instead of type.
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