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Notes/Casey Dahl/Jun 22, 2026, 3:30 PM
CD

Note · Casey Dahl

completedEVV pendingclient signed·Jun 22, 2026, 3:30 PM · 120 min
Service record
Casey Dahl · Individual community living support (ICLS)
PDF
Jun 22, 20263:30 PM – 5:30 PM · 120 min · 8 unitsMaria Peterscompletedacceptedclient signed
Clock in
Jun 22, 2026, 3:30 PM
44.9841, -93.2560
Clock out
Jun 22, 2026, 5:30 PM
44.9852, -93.2560
Medications on 2026-06-22
  • 20:00Lamotrigine100 mg
  • 08:00Metformin500 mg
  • 20:00Metformin500 mg
Level of interaction
Skills worked on
Daily activitiesPick each activity you did with Casey
  • Assisted Casey with budgeting, paying bills, and tracking spending
  • Assisted Casey with developing and following a weekly activity schedule to reduce idle time and promote active daily routines
  • Assisted Casey with household tasks such as laundry, dishes, and tidying living areas
Support plan goals
Take medications on schedule
Did Casey take scheduled medications with a reminder only?
Progress review
signed by staff
Signatures
  • Caregiversigned Jun 22, 2026, 5:32 PM
  • Clientsigned with code Jun 22, 2026, 5:31 PM
  • Reviewaccepted on submission
Authorization SA-2026-00090PMI 34567890NPI 1234567893POS 12
Accepted Jun 22, 2026, 5:32 PM

Aggregator record

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

Provider tax ID
41-0000000
PMI #
34567890
Service code
H2015 U3
Units
8 × 15 min
Place of service
12 · Home
Rendering staff
Maria Peters · NPI 1234567893
Authorization
SA-2026-00090
Clock in
Jun 22, 2026, 3:30 PM
Clock out
Jun 22, 2026, 5:30 PM
GPS at clock in
44.98413, -93.25597 · ±8 m
GPS at clock out
44.98524, -93.25602 · ±10 m
Manual entry
No
Client signature
Signed with code Jun 22, 2026, 5:31 PM

Tasks

2 of 2 completed

  • Personal care / ADLs
  • Skill building per support plan

Shift note

ICLS session on money management. Casey reviewed the bank balance on the phone app and matched two receipts. Discussed the difference between wants and needs before a purchase.

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Kept with the note and exported as EVV evidence

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