Skip to content
Notes/Riley Bergstrom/Aug 19, 2026, 9:00 AM
RB

Note · Riley Bergstrom

completedEVV pendingclient signed·Aug 19, 2026, 9:00 AM · 120 min
Service record
Riley Bergstrom · Individualized home supports without training, 1:1
PDF
Aug 19, 20269:00 AM – 11:00 AM · 120 min · 8 unitsTobi Okaforcompletedacceptedclient signed
Clock in
Aug 19, 2026, 9:00 AM
44.9831, -93.2618
Clock out
Aug 19, 2026, 11:00 AM
44.9824, -93.2580
Level of interaction
Skills worked on
Daily activitiesPick each activity you did with Riley
  • Accompanied Riley on community outings, providing support as needed to promote comfort and participation
  • Assisted Riley with hygiene routines to promote consistency
  • Supported Riley in practicing coping strategies during moments of stress or frustration
Support plan goals
Bedtime routine
Did Riley complete the bedtime routine with two or fewer prompts?
Progress review
signed by staff
Signatures
  • Caregiversigned Aug 19, 2026, 11:02 AM
  • Clientsigned with code Aug 19, 2026, 11:01 AM
  • Reviewaccepted on submission
Authorization SA-2026-00118PMI 23456789UMPI A100000004POS 12
Accepted Aug 19, 2026, 11:02 AM

Aggregator record

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

Provider tax ID
41-0000000
PMI #
23456789
Service code
S5135 UC
Units
8 × 15 min
Place of service
12 · Home
Rendering staff
Tobi Okafor · UMPI A100000004
Authorization
SA-2026-00118
Clock in
Aug 19, 2026, 9:00 AM
Clock out
Aug 19, 2026, 11:00 AM
GPS at clock in
44.98307, -93.26178 · ±8 m
GPS at clock out
44.98239, -93.25797 · ±10 m
Manual entry
No
Client signature
Signed with code Aug 19, 2026, 11:01 AM

Tasks

2 of 2 completed

  • Personal care / ADLs
  • Skill building per support plan

Shift note

Household tasks and medication reminder. Riley wiped counters and took out recycling with one prompt each. Evening medications taken with reminder only. No concerns.

Edit history

Kept with the note and exported as EVV evidence

No edits since creation.

Edit this note

A reason is required. The change is kept as history and the note is marked manually adjusted for EVV.