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Notes/Riley Bergstrom/Aug 28, 2026, 10:00 AM
RB

Note · Riley Bergstrom

completedEVV pendingclient signed·Aug 28, 2026, 10:00 AM · 90 min
Service record
Riley Bergstrom · Individualized home supports with family training, 1:1
PDF
Aug 28, 202610:00 AM – 11:30 AM · 90 min · 6 unitsMaria Peterscompletedacceptedclient signed
Clock in
Aug 28, 2026, 10:00 AM
44.9835, -93.2642
Clock out
Aug 28, 2026, 11:30 AM
44.9802, -93.2575
Level of interaction
Skills worked on
Daily activitiesPick each activity you did with Riley
  • Assisted Riley with organizing personal belongings and daily tasks
  • Assisted Riley with physical activity or exercise as tolerated
Support plan goals
Bedtime routine
Did Riley complete the bedtime routine with two or fewer prompts?
Progress review
signed by staff
Signatures
  • Caregiversigned Aug 28, 2026, 11:32 AM
  • Clientsigned with code Aug 28, 2026, 11:31 AM
  • Reviewaccepted on submission
Authorization SA-2026-00119PMI 23456789NPI 1234567893POS 12
Accepted Aug 28, 2026, 11:32 AM

Aggregator record

Exactly what the EVV aggregator and the 837P claim line receive

Provider tax ID
41-0000000
PMI #
23456789
Service code
S5125 UC
Units
6 × 15 min
Place of service
12 · Home
Rendering staff
Maria Peters · NPI 1234567893
Authorization
SA-2026-00119
Clock in
Aug 28, 2026, 10:00 AM
Clock out
Aug 28, 2026, 11:30 AM
GPS at clock in
44.98350, -93.26420 · ±8 m
GPS at clock out
44.98020, -93.25751 · ±10 m
Manual entry
No
Client signature
Signed with code Aug 28, 2026, 11:31 AM

Tasks

2 of 2 completed

  • Personal care / ADLs
  • Skill building per support plan

Shift note

Family training session with Riley's mother present. Modeled the two-prompt bedtime routine and coached mom through it. Mom ran the last step alone. Left a printed routine card on the fridge.

Edit history

Kept with the note and exported as EVV evidence

No edits since creation.

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