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Notes/Taylor Frey/Aug 15, 2026, 4:00 PM
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Note · Taylor Frey

completedEVV pendingclient signed·Aug 15, 2026, 4:00 PM · 360 min
Service record
Taylor Frey · Respite care, out of home
PDF
Aug 15, 20264:00 PM – 10:00 PM · 360 min · 24 unitsMaria Peterscompletedacceptedclient signed
Clock in
Aug 15, 2026, 4:00 PM
44.9831, -93.2635
Clock out
Aug 15, 2026, 10:00 PM
44.9844, -93.2571
Level of interaction
Skills worked on
Daily activitiesPick each activity you did with Taylor
  • Assisted Taylor with hygiene routines to promote consistency
  • Assisted Taylor with household tasks such as laundry, dishes, and tidying living areas
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 15, 2026, 10:02 PM
  • Clientsigned with code Aug 15, 2026, 10:01 PM
  • Reviewaccepted on submission
Authorization SA-2026-00133PMI 45678901NPI 1234567893POS 99
Accepted Aug 15, 2026, 10:02 PM

Aggregator record

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

Provider tax ID
41-0000000
PMI #
45678901
Service code
S5150 UB
Units
24 × 15 min
Place of service
99 · Other / community
Rendering staff
Maria Peters · NPI 1234567893
Authorization
SA-2026-00133
Clock in
Aug 15, 2026, 4:00 PM
Clock out
Aug 15, 2026, 10:00 PM
GPS at clock in
44.98311, -93.26354 · ±8 m
GPS at clock out
44.98442, -93.25708 · ±10 m
Manual entry
No
Client signature
Signed with code Aug 15, 2026, 10:01 PM

Tasks

2 of 2 completed

  • Personal care / ADLs
  • Skill building per support plan

Shift note

Out-of-home respite. Taylor went to the community pool with the group, then a pizza night. Some anxiety at bedtime; staff sat nearby and Taylor was asleep by 10:30.

Edit history

Kept with the note and exported as EVV evidence

No edits since creation.

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