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Notes/Casey Dahl/Aug 17, 2026, 3:30 PM
CD

Note · Casey Dahl

completedEVV pendingclient signed·Aug 17, 2026, 3:30 PM · 120 min
Service record
Casey Dahl · Individual community living support (ICLS)
PDF
Aug 17, 20263:30 PM – 5:30 PM · 120 min · 8 unitsMaria Peterscompletedacceptedclient signed
Clock in
Aug 17, 2026, 3:30 PM
44.9825, -93.2586
Clock out
Aug 17, 2026, 5:30 PM
44.9821, -93.2636
Medications on 2026-08-17
  • 20:00Lamotrigine100 mggiven
  • 08:00Metformin500 mggiven
  • 20:00Metformin500 mggiven
Level of interaction
Skills worked on
Daily activitiesPick each activity you did with Casey
  • Assisted Casey with meal planning, grocery shopping, and preparing a meal
  • Assisted Casey with organizing personal belongings and daily tasks
  • Supported Casey in contacting family, friends, or providers to stay connected
Support plan goals
Take medications on schedule
Did Casey take scheduled medications with a reminder only?
Progress review
signed by staff
Signatures
  • Caregiversigned Aug 17, 2026, 5:32 PM
  • Clientsigned with code Aug 17, 2026, 5:31 PM
  • Reviewaccepted on submission
Authorization SA-2026-00090PMI 34567890NPI 1234567893POS 12
Accepted Aug 17, 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
Aug 17, 2026, 3:30 PM
Clock out
Aug 17, 2026, 5:30 PM
GPS at clock in
44.98254, -93.25864 · ±8 m
GPS at clock out
44.98214, -93.26364 · ±10 m
Manual entry
No
Client signature
Signed with code Aug 17, 2026, 5:31 PM

Tasks

2 of 2 completed

  • Personal care / ADLs
  • Skill building per support plan

Shift note

ICLS session on money management. Casey reviewed the bank balance on the phone app and matched two receipts. Discussed the difference between wants and needs before a purchase.

Edit history

Kept with the note and exported as EVV evidence

No edits since creation.

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