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Notes/Riley Bergstrom/Aug 25, 2026, 3:00 PM
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Note · Riley Bergstrom

completedEVV pendingclient signed·Aug 25, 2026, 3:00 PM · 240 min
Service record
Riley Bergstrom · Respite care, in home
PDF
Aug 25, 20263:00 PM – 7:00 PM · 240 min · 16 unitsSam Nguyencompletedacceptedclient signed
Clock in
Aug 25, 2026, 3:00 PM
44.9863, -93.2550
Clock out
Aug 25, 2026, 7:00 PM
44.9844, -93.2559
Level of interaction
Skills worked on
Daily activitiesPick each activity you did with Riley
  • Assisted Riley with setting boundaries and navigating social interactions
  • Assisted Riley with setting up reminders and systems for appointments and scheduled events
  • Assisted Riley with organizing personal belongings and daily tasks
Support plan goals
Bedtime routine
Did Riley complete the bedtime routine with two or fewer prompts?
Progress review
signed by staff
Signatures
  • Caregiversigned Aug 25, 2026, 7:02 PM
  • Clientsigned with code Aug 25, 2026, 7:01 PM
  • Reviewaccepted on submission
Authorization SA-2026-00117PMI 23456789UMPI A100000003POS 12
Accepted Aug 25, 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 25, 2026, 3:00 PM
Clock out
Aug 25, 2026, 7:00 PM
GPS at clock in
44.98631, -93.25502 · ±8 m
GPS at clock out
44.98440, -93.25586 · ±10 m
Manual entry
No
Client signature
Signed with code Aug 25, 2026, 7:01 PM

Tasks

2 of 2 completed

  • Personal care / ADLs
  • Skill building per support plan

Shift note

Respite at home while parent was at work. Playground, snack, and a board game. Bedtime routine started at 8:15 with two prompts. Fell asleep by 8:45. No concerns.

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Kept with the note and exported as EVV evidence

No edits since creation.

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