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Table 2 Description of fall risk assessment tools used in SCI rehabilitation settings. Column three represents the maximum score (a high score infers a higher fall risk). The thresholds for assigning fall risk based on the scores are specified in column four

From: Current state of fall prevention and management policies and procedures in Canadian spinal cord injury rehabilitation

Scale NameDomains EvaluatedMaximum ScoreInterpretation
STRATIFY [17]recent falls, agitation, vision, toileting frequency, transfers and mobility60 = low fall risk
1 = medium fall risk
2 + = high fall risk
Schmid Fall Risk Assessment Tool [18]mobility, mentation, elimination, prior fall history and current medications, agitation, attempting to get out of bed unsafely, vision, orthostatic hypotension, balance and sensory issues, history of fractures or osteoporosis, alcohol/substance abuse and malnutrition50–2 = normal fall risk
≥3 = high fall risk
Morse Fall Scale [19]fall history, secondary diagnosis, ambulatory aid, IV, gait/transfers, and cognition1250–24 = low fall risk
25–44 = moderate fall risk
≥45 = high fall risk
Customized Scale Site Dhistory of falls, medication, dizziness, sensory impairments, toileting, cognitive impairments, balance/mobility issues, co-morbidities, bed transfers/mobility, mobility in patient room, bathroom and on the unit, and behavioural traits (e.g. judgement, self-control/impulsivity, anxiety)Yes or No scaleAny yes answer requires development of a plan
Customized Scale Site Eneuromuscular deficits, cognition, sensory deficits, bowel/bladder, postural hypotension, history of seizures170 = low fall risk
≥1 = high fall risk
Customized Scale Site F
*based on the Morse fall scale
number of diagnoses, vision, toileting, medication, mobility, and cognition1000–64 = low fall risk
≥65 = high fall risk