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Notes/Casey Dahl/Aug 5, 2026, 1:00 PM
CD

Note · Casey Dahl

completedEVV pendingclient signed·Aug 5, 2026, 1:00 PM · 120 min
Service record
Casey Dahl · Individualized home supports without training, 1:1
PDF
Aug 5, 20261:00 PM – 3:00 PM · 120 min · 8 unitsTobi Okaforcompletedacceptedclient signed
Clock in
Aug 5, 2026, 1:00 PM
44.9800, -93.2569
Clock out
Aug 5, 2026, 3:00 PM
44.9797, -93.2612
Medications on 2026-08-05
  • 20:00Lamotrigine100 mggiven
  • 08:00Metformin500 mggiven
  • 20:00Metformin500 mggiven
Level of interaction
Skills worked on
Daily activitiesPick each activity you did with Casey
  • Assisted Casey with hygiene routines to promote consistency
  • Assisted Casey with household tasks such as laundry, dishes, and tidying living areas
  • Supported Casey with medication reminders and monitoring for side effects
Support plan goals
Take medications on schedule
Did Casey take scheduled medications with a reminder only?
Progress review
signed by staff
Signatures
  • Caregiversigned Aug 5, 2026, 3:02 PM
  • Clientsigned with code Aug 5, 2026, 3:01 PM
  • Reviewaccepted on submission
Authorization SA-2026-00088PMI 34567890UMPI A100000004POS 12
Accepted Aug 5, 2026, 3:02 PM

Aggregator record

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

Provider tax ID
41-0000000
PMI #
34567890
Service code
S5135 UC
Units
8 × 15 min
Place of service
12 · Home
Rendering staff
Tobi Okafor · UMPI A100000004
Authorization
SA-2026-00088
Clock in
Aug 5, 2026, 1:00 PM
Clock out
Aug 5, 2026, 3:00 PM
GPS at clock in
44.98002, -93.25691 · ±8 m
GPS at clock out
44.97966, -93.26120 · ±10 m
Manual entry
No
Client signature
Signed with code Aug 5, 2026, 3:01 PM

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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