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Notes/Riley Bergstrom/Aug 17, 2026, 9:00 AM
RB

Note · Riley Bergstrom

completedEVV pendingclient signed·Aug 17, 2026, 9:00 AM · 120 min
Service record
Riley Bergstrom · Individualized home supports without training, 1:1
PDF
Aug 17, 20269:00 AM – 11:00 AM · 120 min · 8 unitsTobi Okaforcompletedacceptedclient signed
Clock in
Aug 17, 2026, 9:00 AM
44.9833, -93.2630
Clock out
Aug 17, 2026, 11:00 AM
44.9859, -93.2605
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
Support plan goals
Bedtime routine
Did Riley complete the bedtime routine with two or fewer prompts?
Progress review
signed by staff
Signatures
  • Caregiversigned Aug 17, 2026, 11:02 AM
  • Clientsigned with code Aug 17, 2026, 11:01 AM
  • Reviewaccepted on submission
Authorization SA-2026-00118PMI 23456789UMPI A100000004POS 12
Accepted Aug 17, 2026, 11:02 AM

Aggregator record

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

Provider tax ID
41-0000000
PMI #
23456789
Service code
S5135 UC
Units
8 × 15 min
Place of service
12 · Home
Rendering staff
Tobi Okafor · UMPI A100000004
Authorization
SA-2026-00118
Clock in
Aug 17, 2026, 9:00 AM
Clock out
Aug 17, 2026, 11:00 AM
GPS at clock in
44.98331, -93.26302 · ±8 m
GPS at clock out
44.98585, -93.26051 · ±10 m
Manual entry
No
Client signature
Signed with code Aug 17, 2026, 11:01 AM

Tasks

2 of 2 completed

  • Personal care / ADLs
  • Skill building per support plan

Shift note

Supported grocery put-away and meal prep for tomorrow. Practiced using the microwave safely. Riley chose to call grandmother afterward. Calm evening.

Edit history

Kept with the note and exported as EVV evidence

No edits since creation.

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