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Notes/Taylor Frey/Aug 6, 2026, 9:00 AM
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Note · Taylor Frey

completedEVV pendingclient signed·Aug 6, 2026, 9:00 AM · 300 min
Service record
Taylor Frey · Day support services
PDF
Aug 6, 20269:00 AM – 2:00 PM · 300 min · 20 unitsSam Nguyencompletedacceptedclient signed
Clock in
Aug 6, 2026, 9:00 AM
44.9846, -93.2628
Clock out
Aug 6, 2026, 2:00 PM
44.9846, -93.2650
Level of interaction
Skills worked on
Daily activitiesPick each activity you did with Taylor
  • Assisted Taylor with household tasks such as laundry, dishes, and tidying living areas
  • Supported Taylor in practicing coping strategies during moments of stress or frustration
Support plan goals
Live in my own apartment
Did Taylor cook or plan a meal today?
Did Taylor complete a chore from the checklist without a prompt?
Progress review
signed by staff
Signatures
  • Caregiversigned Aug 6, 2026, 2:02 PM
  • Clientsigned with code Aug 6, 2026, 2:01 PM
  • Reviewaccepted on submission
Authorization SA-2026-00132PMI 45678901UMPI A100000003POS 99
Accepted Aug 6, 2026, 2:02 PM

Aggregator record

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

Provider tax ID
41-0000000
PMI #
45678901
Service code
T2021 UC
Units
20 × 15 min
Place of service
99 · Other / community
Rendering staff
Sam Nguyen · UMPI A100000003
Authorization
SA-2026-00132
Clock in
Aug 6, 2026, 9:00 AM
Clock out
Aug 6, 2026, 2:00 PM
GPS at clock in
44.98456, -93.26284 · ±8 m
GPS at clock out
44.98462, -93.26498 · ±10 m
Manual entry
No
Client signature
Signed with code Aug 6, 2026, 2:01 PM

Tasks

2 of 2 completed

  • Personal care / ADLs
  • Skill building per support plan

Shift note

Day support. Cooking class (quesadillas). Taylor followed the recipe and shared with the table. Afternoon board games; managed losing a round without frustration.

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Kept with the note and exported as EVV evidence

No edits since creation.

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