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Notes/Riley Bergstrom/Aug 26, 2026, 9:00 AM
RB

Note · Riley Bergstrom

completedEVV pendingclient signed·Aug 26, 2026, 9:00 AM · 120 min
Service record
Riley Bergstrom · Individualized home supports without training, 1:1
PDF
Aug 26, 20269:00 AM – 11:00 AM · 120 min · 8 unitsTobi Okaforcompletedacceptedclient signed
Clock in
Aug 26, 2026, 9:00 AM
44.9820, -93.2575
Clock out
Aug 26, 2026, 11:00 AM
44.9816, -93.2641
Level of interaction
Skills worked on
Daily activitiesPick each activity you did with Riley
  • Supported Riley in practicing coping strategies during moments of stress or frustration
  • Accompanied Riley on community outings, providing support as needed to promote comfort and participation
  • Assisted Riley with developing and following a weekly activity schedule to reduce idle time and promote active daily routines
Support plan goals
Bedtime routine
Did Riley complete the bedtime routine with two or fewer prompts?
Progress review
signed by staff
Signatures
  • Caregiversigned Aug 26, 2026, 11:02 AM
  • Clientsigned with code Aug 26, 2026, 11:01 AM
  • Reviewaccepted on submission
Authorization SA-2026-00118PMI 23456789UMPI A100000004POS 12
Accepted Aug 26, 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 26, 2026, 9:00 AM
Clock out
Aug 26, 2026, 11:00 AM
GPS at clock in
44.98199, -93.25755 · ±8 m
GPS at clock out
44.98164, -93.26410 · ±10 m
Manual entry
No
Client signature
Signed with code Aug 26, 2026, 11:01 AM

Tasks

2 of 2 completed

  • Personal care / ADLs
  • Skill building per support plan

Shift note

Casey completed the kitchen routine (dishes, wipe-down, trash) with a checklist and no prompts. Medications taken on time. Watched a show together and talked about weekend plans.

Edit history

Kept with the note and exported as EVV evidence

No edits since creation.

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