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Formulir Pengkajian Resiko Jatuh MorseRSIJ Cempaka PutihJl. Cempaka Putih Tengah No.1Tanggal masuk ruang rawat :................... pukul :................. Ruang Rawat :.........................................PEMANTAUAN RESIKO JATUH PASIEN DEWASABERDASARKAN PENILAIAN Skala Morse/ Morse Falls Scale (MFS) NO PENGKAJIAN SKALA Skoring 1 Skoring 2 Skoring 3Saat Masuk Tgl Tgl1. Riwayat jatuh: apakah pasien pernah jatuhdalam 3 bulan terakhir?Tidak 0Ya 252. Diagnosa sekunder: apakah pasienmemilikilebih dari satu penyakit?Tidak 0Ya 153. Alat Bantu jalan:- Bed rest/ dibantu perawat 0- Kruk/ tongkat/ walker 15- Berpegangan pada benda-benda disekitar 304. Terapi Intravena: apakah saat ini pasienterpasang infus?Tidak 0Ya 205. Gaya berjalan/ cara berpindah:- Normal/ bed rest/ immobile(tidak dapat bergerak sendiri)0- Lemah (tidak bertenaga) 10- Gangguan/ tidak normal (pincang/diseret)206. Status Mental- Pasien menyadari kondisi dirinya 0- Pasien mengalami keterbatasan dayaingat15 Total NilaiPara

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