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The MFS is divided into ranges: a low fall risk score is below 25, a medium risk is between 25 and 50 and high risk for falling is 51 or higher. The MFS has shown sensitivity scores between 72% and 88% and specificity scores between 29% and 83%.
Patient Score Normal/bedrest/wheelchair0Weak*10Impaired20
Get up and go test scores range from 0 to 4 based on the patients ability to rise from a seated position as shown in the table at the beginning of the article.
TARGET POPULATION: The Hendrich II Fall Risk ModelTM is intended to be used in the acute care setting to identify adults at risk for falls. The Model is being validated for further application of the specific risk factors in pediatrics and obstetrical populations.
Determine the clients risk classification level (risk status) by adding the 4 scores from Part 1 Low risk 511 Medium risk 1215 High risk 1620 Persons with a risk classification of 1620 require a Fall Alert Protocol to be actioned.
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During an assessment, your provider will test your strength, balance, and gait, using the following fall assessment tools: Timed Up-and-Go (Tug). This test checks your gait. 30-Second Chair Stand Test. This test checks strength and balance. 4-Stage Balance Test. This test checks how well you can keep your balance.
Score 0125. 020 No risk or low risk; 25 Medium risk; 45, 5055 High risk.
The most commonly used fall risk assessment tools were the Morse Fall Scale and the Performance-Oriented Mobility Scale.

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