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

Note · Casey Dahl

completedEVV pendingclient signed·Jul 13, 2026, 3:30 PM · 120 min
Service record
Casey Dahl · Individual community living support (ICLS)
PDF
Jul 13, 20263:30 PM – 5:30 PM · 120 min · 8 unitsMaria Peterscompletedacceptedclient signed
Clock in
Jul 13, 2026, 3:30 PM
44.9827, -93.2550
Clock out
Jul 13, 2026, 5:30 PM
44.9800, -93.2579
Medications on 2026-07-13
  • 20:00Lamotrigine100 mg
  • 08:00Metformin500 mg
  • 20:00Metformin500 mg
Level of interaction
Skills worked on
Daily activitiesPick each activity you did with Casey
  • Supported Casey in contacting family, friends, or providers to stay connected
  • Assisted Casey with setting boundaries and navigating social interactions
Support plan goals
Take medications on schedule
Did Casey take scheduled medications with a reminder only?
Progress review
signed by staff
Signatures
  • Caregiversigned Jul 13, 2026, 5:32 PM
  • Clientsigned with code Jul 13, 2026, 5:31 PM
  • Reviewaccepted on submission
Authorization SA-2026-00090PMI 34567890NPI 1234567893POS 12
Accepted Jul 13, 2026, 5:32 PM

Aggregator record

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

Provider tax ID
41-0000000
PMI #
34567890
Service code
H2015 U3
Units
8 × 15 min
Place of service
12 · Home
Rendering staff
Maria Peters · NPI 1234567893
Authorization
SA-2026-00090
Clock in
Jul 13, 2026, 3:30 PM
Clock out
Jul 13, 2026, 5:30 PM
GPS at clock in
44.98272, -93.25504 · ±8 m
GPS at clock out
44.97999, -93.25792 · ±10 m
Manual entry
No
Client signature
Signed with code Jul 13, 2026, 5:31 PM

Tasks

2 of 2 completed

  • Personal care / ADLs
  • Skill building per support plan

Shift note

Worked on scheduling: Casey booked a dentist appointment by phone with a script and staff prompting only at the end. Added it to the paper calendar and phone reminder.

Edit history

Kept with the note and exported as EVV evidence

No edits since creation.

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