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Notes/Casey Dahl/Aug 20, 2026, 3:30 PM
CD

Note · Casey Dahl

completedEVV pendingclient signed·Aug 20, 2026, 3:30 PM · 90 min
Service record
Casey Dahl · Homemaker, home management
PDF
Aug 20, 20263:30 PM – 5:00 PM · 90 min · 6 unitsTobi Okaforcompletedacceptedclient signed
Clock in
Aug 20, 2026, 3:30 PM
44.9793, -93.2642
Clock out
Aug 20, 2026, 5:00 PM
44.9833, -93.2643
Medications on 2026-08-20
  • 20:00Lamotrigine100 mggiven
  • 08:00Metformin500 mggiven
  • 20:00Metformin500 mgmissed
Level of interaction
Skills worked on
Daily activitiesPick each activity you did with Casey
  • Assisted Casey with setting up reminders and systems for appointments and scheduled events
  • Modeled and practiced communication skills with Casey in a natural setting
  • Assisted Casey with budgeting, paying bills, and tracking spending
Support plan goals
Take medications on schedule
Did Casey take scheduled medications with a reminder only?
Progress review
signed by staff
Signatures
  • Caregiversigned Aug 20, 2026, 5:02 PM
  • Clientsigned with code Aug 20, 2026, 5:01 PM
  • Reviewaccepted on submission
Authorization SA-2026-00089PMI 34567890UMPI A100000004POS 12
Accepted Aug 20, 2026, 5:02 PM

Aggregator record

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

Provider tax ID
41-0000000
PMI #
34567890
Service code
S5130 TF
Units
6 × 15 min
Place of service
12 · Home
Rendering staff
Tobi Okafor · UMPI A100000004
Authorization
SA-2026-00089
Clock in
Aug 20, 2026, 3:30 PM
Clock out
Aug 20, 2026, 5:00 PM
GPS at clock in
44.97932, -93.26420 · ±8 m
GPS at clock out
44.98327, -93.26433 · ±10 m
Manual entry
No
Client signature
Signed with code Aug 20, 2026, 5:01 PM

Tasks

2 of 2 completed

  • Personal care / ADLs
  • Skill building per support plan

Shift note

Homemaker, home management. Sorted mail, paid the electric bill online with Casey watching, and planned the week's meals. Made a shopping list for Thursday.

Edit history

Kept with the note and exported as EVV evidence

No edits since creation.

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