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Notes/Casey Dahl/Jul 27, 2026, 3:30 PM
CD

Note · Casey Dahl

completedEVV pendingclient signed·Jul 27, 2026, 3:30 PM · 120 min
Service record
Casey Dahl · Individual community living support (ICLS)
PDF
Jul 27, 20263:30 PM – 5:30 PM · 120 min · 8 unitsMaria Peterscompletedacceptedclient signed
Clock in
Jul 27, 2026, 3:30 PM
44.9836, -93.2640
Clock out
Jul 27, 2026, 5:30 PM
44.9843, -93.2641
Medications on 2026-07-27
  • 20:00Lamotrigine100 mg
  • 08:00Metformin500 mg
  • 20:00Metformin500 mg
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 Jul 27, 2026, 5:32 PM
  • Clientsigned with code Jul 27, 2026, 5:31 PM
  • Reviewaccepted on submission
Authorization SA-2026-00090PMI 34567890NPI 1234567893POS 12
Accepted Jul 27, 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 27, 2026, 3:30 PM
Clock out
Jul 27, 2026, 5:30 PM
GPS at clock in
44.98364, -93.26404 · ±8 m
GPS at clock out
44.98429, -93.26406 · ±10 m
Manual entry
No
Client signature
Signed with code Jul 27, 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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