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Notes/Casey Dahl/Aug 13, 2026, 3:30 PM
CD

Note · Casey Dahl

completedEVV pendingclient signed·Aug 13, 2026, 3:30 PM · 90 min
Service record
Casey Dahl · Homemaker, home management
PDF
Aug 13, 20263:30 PM – 5:00 PM · 90 min · 6 unitsTobi Okaforcompletedacceptedclient signed
Clock in
Aug 13, 2026, 3:30 PM
44.9874, -93.2633
Clock out
Aug 13, 2026, 5:00 PM
44.9834, -93.2615
Medications on 2026-08-13
  • 20:00Lamotrigine100 mggiven
  • 08:00Metformin500 mggiven
  • 20:00Metformin500 mggiven
Level of interaction
Skills worked on
Daily activitiesPick each activity you did with Casey
  • Provided supervision and safety monitoring throughout the service
  • Assisted Casey with meal planning, grocery shopping, and preparing a meal
Support plan goals
Take medications on schedule
Did Casey take scheduled medications with a reminder only?
Progress review
signed by staff
Signatures
  • Caregiversigned Aug 13, 2026, 5:02 PM
  • Clientsigned with code Aug 13, 2026, 5:01 PM
  • Reviewaccepted on submission
Authorization SA-2026-00089PMI 34567890UMPI A100000004POS 12
Accepted Aug 13, 2026, 5:02 PM

Aggregator record

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

Provider tax ID
41-0000000
PMI #
34567890
Service code
S5130 TF
Units
6 × 15 min
Place of service
12 · Home
Rendering staff
Tobi Okafor · UMPI A100000004
Authorization
SA-2026-00089
Clock in
Aug 13, 2026, 3:30 PM
Clock out
Aug 13, 2026, 5:00 PM
GPS at clock in
44.98744, -93.26333 · ±8 m
GPS at clock out
44.98342, -93.26149 · ±10 m
Manual entry
No
Client signature
Signed with code Aug 13, 2026, 5:01 PM

Tasks

2 of 2 completed

  • Personal care / ADLs
  • Skill building per support plan

Shift note

Deep-cleaned the bathroom and changed bed linens. Organized the medication cabinet and discarded an expired bottle with Casey's agreement. Set out clothes for the week.

Edit history

Kept with the note and exported as EVV evidence

No edits since creation.

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