RB
Note · Riley Bergstrom
completedEVV pendingmanual entryclient signed·Aug 22, 2026, 3:00 PM · 240 min
Service record
Riley Bergstrom · Respite care, in home
Authorization SA-2026-00117PMI 23456789UMPI A100000003POS 12
Manual entry: Phone died; times confirmed with guardian
Accepted Aug 22, 2026, 7:02 PM
Aggregator record
Exactly what the EVV aggregator and the 837P claim line receive
- Provider tax ID
- 41-0000000
- PMI #
- 23456789
- Service code
- S5150
- Units
- 16 × 15 min
- Place of service
- 12 · Home
- Rendering staff
- Sam Nguyen · UMPI A100000003
- Authorization
- SA-2026-00117
- Clock in
- Aug 22, 2026, 3:00 PM
- Clock out
- Aug 22, 2026, 7:00 PM
- GPS at clock in
- 44.98255, -93.26300 · ±8 m
- GPS at clock out
- 44.98388, -93.25719 · ±10 m
- Manual entry
- yes Phone died; times confirmed with guardian
- Client signature
- Signed with code Aug 22, 2026, 7:01 PM
Tasks
2 of 2 completed
- Personal care / ADLs
- Skill building per support plan
Shift note
Afternoon respite. Walked to the park, then homework support for 30 minutes. Dinner eaten fully. Brushed teeth with one reminder. Parent returned at 7:00 and staff gave a handoff.
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Kept with the note and exported as EVV evidence
No edits since creation.
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