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Notes/Casey Dahl/Aug 31, 2026, 3:30 PM
CD

Note · Casey Dahl

completedEVV pendingclient signed·Aug 31, 2026, 3:30 PM · 120 min
Service record
Casey Dahl · Individual community living support (ICLS)
PDF
Aug 31, 20263:30 PM – 5:30 PM · 120 min · 8 unitsMaria Peterscompletedreturnedclient signed
Clock in
Aug 31, 2026, 3:30 PM
44.9868, -93.2557
Clock out
Aug 31, 2026, 5:30 PM
44.9856, -93.2558
Medications on 2026-08-31
  • 20:00Lamotrigine100 mggiven
  • 08:00Metformin500 mggiven
  • 20:00Metformin500 mggiven
Level of interaction
Skills worked on
Daily activitiesPick each activity you did with Casey
  • Modeled and practiced communication skills with Casey in a natural setting
  • Supported Casey in contacting family, friends, or providers to stay connected
  • Provided supervision and safety monitoring throughout the service
Support plan goals
Take medications on schedule
Did Casey take scheduled medications with a reminder only?
Progress review
signed by staff
Signatures
  • Caregiversigned Aug 31, 2026, 5:32 PM
  • Clientsigned with code Aug 31, 2026, 5:31 PM
  • Reviewreturned Aug 31, 2026, 7:30 PM by Mustafa Ali: Add what prompting you gave during the community outing.
Authorization SA-2026-00090PMI 34567890NPI 1234567893POS 12
Returned for correction Aug 31, 2026, 7:30 PM: Add what prompting you gave during the community outing.

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
Aug 31, 2026, 3:30 PM
Clock out
Aug 31, 2026, 5:30 PM
GPS at clock in
44.98684, -93.25566 · ±8 m
GPS at clock out
44.98561, -93.25583 · ±10 m
Manual entry
No
Client signature
Signed with code Aug 31, 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.

Edit history

Kept with the note and exported as EVV evidence

No edits since creation.

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