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History of falling: This is scored as 25 if the patient has fallen during the present hospital admission or if there was an immediate history of physiological falls, such as from seizures or an impaired gait prior to admission. If the patient has not fallen, this is scored 0.
A patient who scores under 25 points is considered to be at low risk of falling, a patient who scores between 2545 points is considered to be at moderate risk of falling, and a patient who scores higher than 45 points is considered to be at high risk of falling.
A patient who scores under 25 points is considered to be at low risk of falling, a patient who scores between 2545 points is considered to be at moderate risk of falling, and a patient who scores higher than 45 points is considered to be at high risk of falling.
MFS scores range from 0 to 125: 0-24: Low risk. 25-45: Moderate risk. 46+: High risk.
Risk LevelMorse Fall Scale ScoreActionLow Risk0 24Implement Low Risk Fall Prevention InterventionsMedium Risk25 44Implement Medium Risk Fall Prevention InterventionsHigh Risk45 and higherImplement High Risk Fall Prevention Interventions
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Scores below 25 indicate a low fall risk, scores between 25 and 45 indicate a moderate risk whilst scores above 45 suggest the patient is at a high fall risk.
Ambulatory Aids: Score 0: If the patient walks without a walking aid (even if assisted by a nurse), uses a wheelchair, or is on a bed rest and does not get out of bed at all. Score 15: If the patient uses crutches, a cane, or a walker. Score 30: If the patient ambulates clutching onto the furniture for support.
History of falling: This is scored as 25 if the patient has fallen during the present hospital admission or if there was an immediate history of physiological falls, such as from seizures or an impaired gait prior to admission. If the patient has not fallen, this is scored 0.
Scores below 25 indicate a low fall risk, scores between 25 and 45 indicate a moderate risk whilst scores above 45 suggest the patient is at a high fall risk.
Morse Fall Scale ItemPatient Score6. Mental statusOriented to own ability 0 Overestimates/forgets limitations 15Total Score: Tally the patient score and record. 0: No risk for falls 45: High risk7 more rows

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