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Notes/Riley Bergstrom/Aug 29, 2026, 3:00 PM
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Note · Riley Bergstrom

completedEVV pendingclient signed·Aug 29, 2026, 3:00 PM · 240 min
Service record
Riley Bergstrom · Respite care, in home
PDF
Aug 29, 20263:00 PM – 7:00 PM · 240 min · 16 unitsSam Nguyencompletedacceptedclient signed
Clock in
Aug 29, 2026, 3:00 PM
44.9807, -93.2596
Clock out
Aug 29, 2026, 7:00 PM
44.9870, -93.2608
Level of interaction
Skills worked on
Daily activitiesPick each activity you did with Riley
  • Assisted Riley with household tasks such as laundry, dishes, and tidying living areas
  • Supported Riley in practicing coping strategies during moments of stress or frustration
Support plan goals
Bedtime routine
Did Riley complete the bedtime routine with two or fewer prompts?
Progress review
signed by staff
Signatures
  • Caregiversigned Aug 29, 2026, 7:02 PM
  • Clientsigned with code Aug 29, 2026, 7:01 PM
  • Reviewaccepted on submission
Authorization SA-2026-00117PMI 23456789UMPI A100000003POS 12
Accepted Aug 29, 2026, 7:02 PM

Aggregator record

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

Provider tax ID
41-0000000
PMI #
23456789
Service code
S5150
Units
16 × 15 min
Place of service
12 · Home
Rendering staff
Sam Nguyen · UMPI A100000003
Authorization
SA-2026-00117
Clock in
Aug 29, 2026, 3:00 PM
Clock out
Aug 29, 2026, 7:00 PM
GPS at clock in
44.98068, -93.25962 · ±8 m
GPS at clock out
44.98705, -93.26075 · ±10 m
Manual entry
No
Client signature
Signed with code Aug 29, 2026, 7:01 PM

Tasks

2 of 2 completed

  • Personal care / ADLs
  • Skill building per support plan

Shift note

Afternoon respite. Walked to the park, then homework support for 30 minutes. Dinner eaten fully. Brushed teeth with one reminder. Parent returned at 7:00 and staff gave a handoff.

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Kept with the note and exported as EVV evidence

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