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Notes/Casey Dahl/Jun 29, 2026, 3:30 PM
CD

Note · Casey Dahl

completedEVV pendingclient signed·Jun 29, 2026, 3:30 PM · 120 min
Service record
Casey Dahl · Individual community living support (ICLS)
PDF
Jun 29, 20263:30 PM – 5:30 PM · 120 min · 8 unitsMaria Peterscompletedacceptedclient signed
Clock in
Jun 29, 2026, 3:30 PM
44.9865, -93.2601
Clock out
Jun 29, 2026, 5:30 PM
44.9802, -93.2645
Medications on 2026-06-29
  • 20:00Lamotrigine100 mg
  • 08:00Metformin500 mg
  • 20:00Metformin500 mg
Level of interaction
Skills worked on
Daily activitiesPick each activity you did with Casey
  • Assisted Casey with coordinating transportation to events, appointments, and social outings
  • Supported Casey with medication reminders and monitoring for side effects
Support plan goals
Take medications on schedule
Did Casey take scheduled medications with a reminder only?
Progress review
signed by staff
Signatures
  • Caregiversigned Jun 29, 2026, 5:32 PM
  • Clientsigned with code Jun 29, 2026, 5:31 PM
  • Reviewaccepted on submission
Authorization SA-2026-00090PMI 34567890NPI 1234567893POS 12
Accepted Jun 29, 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
Jun 29, 2026, 3:30 PM
Clock out
Jun 29, 2026, 5:30 PM
GPS at clock in
44.98652, -93.26012 · ±8 m
GPS at clock out
44.98022, -93.26448 · ±10 m
Manual entry
No
Client signature
Signed with code Jun 29, 2026, 5:31 PM

Tasks

2 of 2 completed

  • Personal care / ADLs
  • Skill building per support plan

Shift note

Community living skills: rode the A Line to Rosedale and back, practicing fare card use and stop announcements. Casey identified the correct stop both ways.

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Kept with the note and exported as EVV evidence

No edits since creation.

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