Question 1

Should I use the Morse Scale or the Hendrich II?

Accepted Answer

Both have similar predictive validity (AUC 0.68–0.75). Morse includes specific ambulatory aids and gait assessment; Hendrich II includes a get-up-and-go test and medication items. Many institutions use both, or choose based on nursing workflow. Morse takes under 2 minutes and is more commonly used in surgical units.

Question 2

Can the Morse Scale be used in emergency departments?

Accepted Answer

Yes — it has been validated for ED use. However, an ED-based assessment reflects a snapshot during acute illness, which may overestimate risk. Reassessment after stabilisation and on admission to the ward is recommended. Some institutions use a modified ED version.

Question 3

Does a low Morse score mean the patient is safe from falls?

Accepted Answer

No — no fall risk tool has 100% sensitivity. A low score indicates lower relative risk, but all hospitalised patients should receive standard fall prevention precautions (orientated environment, call bell, non-slip footwear, clear pathways). Clinical judgement should supersede any risk score.

Question 4

How often should the Morse Scale be reassessed?

Accepted Answer

Standard practice is once per shift (every 8–12 hours) for inpatients. Reassessment is also indicated after falls (even if no injury), after any change in mental status or mobility, with new medications affecting balance (sedatives, antihypertensives), and at care transitions (ward transfer, discharge planning).