Place where you collect the data considered relevant to the identification of needs and residual abilities. Almost impossible to practice in some hectic work environments, it is also the most difficult to design. In order not to turn the investigation into a mere exercise, then not being able to use it on the field, you must decide very clearly what we really need.
The conceptual model helps us a lot, but it can distract from the real issue, shifting the focus of the compiler on issues of little importance. It is likely that the draft requires two or more printed pages. This is different from the medical history, however, like the latter, may be recorded in an "unstructured", ie by writing their observations on a simple sheet of paper (perhaps using a lookup table in which to choose data collection).
But this gives rise to two problems, related to the skills of individual nurses and the inability to use, then the data in computer. A data collection with multiple-choice items to be ticked, in addition to greatly simplify the lives of those who work in the department (where the pace of work and the environments do not allow space for reflection), allows entry into a relational database like SQL and then a subsequent revision of statistical data. There are dozens of rating scales that could be used to enrich the "Nursing History Form." There are lots of useful but not essential.
If the resulting score is an indication for any influence with the care process, well, otherwise they are only further loss of time. Instead, they can be very useful planning tools that allow you to calculate the workload.