Which scale is used for fall risk assessment? Key scales explained

Oct 18, 2025 5 min read •

elder care Physical Therapy Patient Safety

According to the Centers for Disease Control and Prevention (CDC), one in four adults aged 65 or older experiences a fall each year. In healthcare, a number of standardized tools are available to help medical professionals determine which scale is used for fall risk assessment for a specific patient, including the widely used Morse Fall Scale (MFS).

Quick Summary

Several clinical tools exist for assessing fall risk, with the Morse Fall Scale being a prominent example, particularly in acute care settings. Other important assessments include the Hendrich II Fall Risk Model, Berg Balance Scale, and Timed Up and Go (TUG) test. These scales evaluate various factors, such as a patient's history, mobility, balance, mental status, and medication use to determine risk levels and inform preventative interventions.

Key Points

Morse Fall Scale (MFS) is a widely used tool: This six-item scale is popular in hospital and long-term care settings for quick, evidence-based fall risk screening.
Hendrich II Fall Risk Model is a specific tool for acute care: The HIIFRM focuses on eight intrinsic risk factors and includes a 'Get-Up-and-Go' test to prompt targeted interventions.
Berg Balance Scale (BBS) measures functional balance: Primarily used by physical therapists, the BBS is a performance-based test consisting of 14 balance tasks to assess and track functional mobility.
Timed Up and Go (TUG) Test is a quick screener: This simple test assesses functional mobility by timing a patient as they stand, walk a short distance, and sit down again; a time over 12 seconds indicates an increased fall risk.
Combined assessments offer comprehensive care: No single scale is perfect, and clinicians often use multiple tools in conjunction with their own judgment to create a holistic and personalized fall prevention plan.
Assessment results guide interventions: The scores from these scales inform specific preventative actions, such as implementing bed alarms, adjusting medications, performing physical therapy, and modifying the environment.

Common Fall Risk Assessment Scales Explained

To proactively address fall risks, especially among older adults, healthcare professionals rely on various assessment tools. These scales provide a structured, evidence-based approach to identifying potential hazards and guiding intervention strategies. While the Morse Fall Scale is very common in hospitals, other scales are better suited for different populations and settings.

The Morse Fall Scale (MFS)

The Morse Fall Scale is one of the most widely used and effective tools for evaluating fall risk, especially in hospital and long-term care settings. This rapid, easy-to-use scale relies on a six-item scoring system to determine a patient's risk level.

History of Falling: A score is assigned if the patient has fallen within the last three months or during the current admission.
Secondary Diagnosis: Points are added if the patient has more than one medical diagnosis.
Ambulatory Aid: The score varies based on the patient's walking aid, from needing no help to relying on furniture for support.
IV Therapy/Heparin Lock: The presence of an IV access point adds points due to potential entanglement and mobility restrictions.
Gait: The nurse assesses the patient's gait, assigning points for weak, impaired, or shuffling movements.
Mental Status: The patient's awareness of their own limitations is evaluated. Forgetting or overestimating one's abilities increases the score.

The total score places the patient in a low, moderate, or high-risk category, which guides the appropriate preventative actions.

Hendrich II Fall Risk Model (HIIFRM)

Developed specifically for the acute care setting, the Hendrich II Fall Risk Model identifies eight key factors contributing to falls. A major strength of this model is its focus on specific risk factors rather than just a total score, allowing for more targeted interventions.

Risk Factors: These include confusion/disorientation/impulsivity, symptomatic depression, altered elimination, dizziness/vertigo, and specific high-risk medication categories.
Functional Status: The model also incorporates the "Get-Up-and-Go" test to assess balance and mobility.
Targeted Interventions: This tool is designed to prompt caregivers toward specific interventions for each identified risk factor.

Berg Balance Scale (BBS)

Unlike the MFS or HIIFRM, the Berg Balance Scale is a performance-based assessment that provides an objective measure of functional balance. It is widely used by physical therapists and is particularly valuable for evaluating balance deficits in neurological patients and older adults.

14-Item Test: The BBS consists of 14 tasks, such as sitting to standing, standing on one leg, and reaching forward while standing, each scored from 0 to 4.
Score Interpretation: The total score is out of 56, with a lower score indicating a greater risk of falling and a higher need for assistance.
Clinical Value: The scale is excellent for tracking a patient's progress over time and determining the need for assistive devices or rehabilitation.

Timed Up and Go Test (TUG)

The Timed Up and Go (TUG) is a quick and simple test used to assess mobility and balance. It is a recommended screening test for falls by the American Geriatrics Society.

Procedure: The patient is timed as they rise from a chair, walk 3 meters, turn, walk back, and sit down again.
Predictive Value: A time of 12 seconds or more suggests a higher risk of falling.
Qualitative Assessment: The TUG also allows clinicians to observe the quality of the patient's gait and balance, providing valuable qualitative information.

Comparison of Key Fall Risk Assessment Scales


Feature	Morse Fall Scale (MFS)	Hendrich II Fall Risk Model (HIIFRM)	Berg Balance Scale (BBS)	Timed Up and Go (TUG) Test
Best for	General acute care, long-term care	Acute care settings, specific risk factors	Performance-based balance assessment	Quick screening, functional mobility
Assesses	History, diagnosis, aids, IV, gait, mental status	Mental status, medications, elimination, dizziness, Get-Up-and-Go	Static and dynamic balance tasks	Time to complete a specific mobility sequence
Method	Nursing staff interview and observation	Clinical observation and patient report	Standardized, 14-item performance test	Timed performance test
Administration	Quick and simple for nurses	Brief to administer, based on specific risk factors	10-15 minutes, typically by a physical therapist	Less than a minute
Limitations	Lower predictive value than some performance tests	Some medications not explicitly listed but covered by other factors	May require more time and specialized personnel	Less comprehensive than multi-factor scales

Creating a Proactive Fall Prevention Plan

Effective fall prevention goes beyond simply using a single scale; it involves combining formal assessment with ongoing observation and tailored interventions. While a nurse might use the Morse Fall Scale to initially screen a patient on admission, a physical therapist may follow up with a Berg Balance Scale assessment to get a more detailed picture of functional ability.

Interventions: Results from these scales directly inform intervention strategies. For a high-risk patient identified by the MFS, this might involve bed alarms, non-slip footwear, and increased supervision. If the Hendrich II model flags a patient for specific medications, a medical provider might review and adjust the patient’s medication regimen.
Personalized Care: Scales like the Berg Balance Scale and TUG are particularly useful for creating personalized physical therapy plans. The results highlight specific mobility deficits that can be targeted with balance exercises, gait training, and strength-building activities.
Environmental Modifications: Assessment tools also guide environmental changes. For a patient identified as high-risk, a clinician may recommend modifications such as clearing clutter, installing grab bars, and improving lighting in the home or hospital room.
Patient and Family Education: Educating patients and their families on fall risks and prevention strategies is a critical component of care. The assessment results can be used to explain to patients and family members why certain precautions are necessary, improving compliance and overall safety.

Conclusion

There is no single "best" scale for every situation, but rather a toolbox of valid assessment scales used for fall risk across different healthcare settings. The Morse Fall Scale is a quick and effective screening tool, the Hendrich II Fall Risk Model focuses on specific modifiable risk factors, and the Berg Balance Scale and Timed Up and Go test offer objective, performance-based measures of balance and mobility. By utilizing the most appropriate scale for a patient's individual needs and environment, healthcare professionals can implement targeted interventions and significantly reduce the likelihood of falls, thereby improving patient safety and outcomes. Combining these scales with clinical judgment and comprehensive care plans provides the most robust defense against the serious consequences of fall-related injuries.

What is the Morse Fall Scale? A Breakdown

The Morse Fall Scale (MFS) is one of the most prominent screening tools used in clinical settings to assess a patient's risk of falling. Designed to be quick and easy for nurses to administer, it calculates a risk score based on six variables: history of falls, secondary diagnoses, ambulatory aid, IV/heparin lock, gait, and mental status. The resulting score helps classify patients into low, moderate, or high-risk categories to guide targeted fall prevention interventions.

How to Administer the MFS

Assess the Six Variables: A nurse answers six questions about the patient's condition.
Calculate the Score: Points are assigned for each positive risk factor, and the total score is tallied.
Determine Risk Level: The score is categorized (e.g., 0-24 is low risk).
Implement Interventions: The care plan is adjusted based on the identified risk level, such as increasing supervision for high-risk patients.

Key Benefits of the MFS

Simplicity and Speed: Can be completed in under 3 minutes.
Evidence-Based: Has demonstrated predictive validity for identifying patients at risk.
Informs Care Plans: Directly guides the implementation of appropriate safety measures.

Frequently Asked Questions

The Morse Fall Scale (MFS) is one of the most widely used and well-known scales for assessing fall risk in hospital and long-term care settings.

The Morse Fall Scale is calculated by assigning points across six categories: history of falling, secondary diagnoses, ambulatory aid, IV/heparin lock, gait, and mental status. The total score determines the patient's fall risk level (low, moderate, or high).

The Hendrich II Fall Risk Model (HIIFRM) is used in acute care settings to identify specific modifiable fall risk factors in patients. It assesses intrinsic factors like mental status, medication use, and balance.

The Berg Balance Scale is a performance-based test that objectively measures a patient's functional balance through a series of 14 tasks. The Morse Fall Scale is a screening tool based on patient history and observations, and is often quicker to administer.

The Timed Up and Go (TUG) test is a simple and quick assessment of functional mobility. It measures the time it takes for a person to stand up from a chair, walk 3 meters, turn, and sit back down.

A score above 45 on the Morse Fall Scale indicates a high risk of falling. Scores between 25 and 45 are considered moderate risk, while a score under 25 is low risk.

While multiple scales can be used, the Timed Up and Go (TUG) test is often recommended for assessing fall risk in community-dwelling older adults due to its simplicity and direct measure of functional mobility.

References

Medical Disclaimer

This content is for informational purposes only and should not replace professional medical advice. Always consult a qualified healthcare provider regarding personal health decisions.