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Notes/Riley Bergstrom/Aug 21, 2026, 10:00 AM
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Note · Riley Bergstrom

completedEVV pendingclient signed·Aug 21, 2026, 10:00 AM · 90 min
Service record
Riley Bergstrom · Individualized home supports with family training, 1:1
PDF
Aug 21, 202610:00 AM – 11:30 AM · 90 min · 6 unitsMaria Peterscompletedacceptedclient signed
Clock in
Aug 21, 2026, 10:00 AM
44.9826, -93.2596
Clock out
Aug 21, 2026, 11:30 AM
44.9869, -93.2573
Level of interaction
Skills worked on
Daily activitiesPick each activity you did with Riley
  • Assisted Riley with budgeting, paying bills, and tracking spending
  • Assisted Riley with developing and following a weekly activity schedule to reduce idle time and promote active daily routines
  • Assisted Riley with household tasks such as laundry, dishes, and tidying living areas
Support plan goals
Bedtime routine
Did Riley complete the bedtime routine with two or fewer prompts?
Progress review
signed by staff
Signatures
  • Caregiversigned Aug 21, 2026, 11:32 AM
  • Clientsigned with code Aug 21, 2026, 11:31 AM
  • Reviewaccepted on submission
Authorization SA-2026-00119PMI 23456789NPI 1234567893POS 12
Accepted Aug 21, 2026, 11:32 AM

Aggregator record

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

Provider tax ID
41-0000000
PMI #
23456789
Service code
S5125 UC
Units
6 × 15 min
Place of service
12 · Home
Rendering staff
Maria Peters · NPI 1234567893
Authorization
SA-2026-00119
Clock in
Aug 21, 2026, 10:00 AM
Clock out
Aug 21, 2026, 11:30 AM
GPS at clock in
44.98265, -93.25959 · ±8 m
GPS at clock out
44.98689, -93.25734 · ±10 m
Manual entry
No
Client signature
Signed with code Aug 21, 2026, 11:31 AM

Tasks

2 of 2 completed

  • Personal care / ADLs
  • Skill building per support plan

Shift note

Family training session with Riley's mother present. Modeled the two-prompt bedtime routine and coached mom through it. Mom ran the last step alone. Left a printed routine card on the fridge.

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Kept with the note and exported as EVV evidence

No edits since creation.

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