Skip to content
Notes/Jordan Abelard/Aug 8, 2026, 10:00 AM
JA

Note · Jordan Abelard

completedEVV pendingclient signed·Aug 8, 2026, 10:00 AM · 240 min
Service record
Jordan Abelard · Respite care, in home
PDF
Aug 8, 202610:00 AM – 2:00 PM · 240 min · 16 unitsSam Nguyencompletedacceptedclient signed
Clock in
Aug 8, 2026, 10:00 AM
44.9837, -93.2617
Clock out
Aug 8, 2026, 2:00 PM
44.9861, -93.2578
Medications on 2026-08-08
  • 09:15Omeprazole20 mggiven
Level of interaction
Skills worked on
Daily activitiesPick each activity you did with Jordan
  • Provided supervision and safety monitoring throughout the service
  • Assisted Jordan with meal planning, grocery shopping, and preparing a meal
Support plan goals
Improve social skills
Did Jordan participate in a community outing?
Did Jordan start a conversation with a peer or staff member today?
Cook two meals a week
Did Jordan help plan or cook a meal today?
Progress review
signed by staff
Signatures
  • Caregiversigned Aug 8, 2026, 2:02 PM
  • Clientsigned with code Aug 8, 2026, 2:01 PM
  • Reviewaccepted on submission
Authorization SA-2026-00102PMI 12345678UMPI A100000003POS 12
Accepted Aug 8, 2026, 2:02 PM

Aggregator record

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

Provider tax ID
41-0000000
PMI #
12345678
Service code
S5150
Units
16 × 15 min
Place of service
12 · Home
Rendering staff
Sam Nguyen · UMPI A100000003
Authorization
SA-2026-00102
Clock in
Aug 8, 2026, 10:00 AM
Clock out
Aug 8, 2026, 2:00 PM
GPS at clock in
44.98369, -93.26171 · ±8 m
GPS at clock out
44.98612, -93.25784 · ±10 m
Manual entry
No
Client signature
Signed with code Aug 8, 2026, 2:01 PM

Tasks

2 of 2 completed

  • Personal care / ADLs
  • Skill building per support plan

Shift note

Respite at home while parent was at work. Playground, snack, and a board game. Bedtime routine started at 8:15 with two prompts. Fell asleep by 8:45. No concerns.

Edit history

Kept with the note and exported as EVV evidence

No edits since creation.

Edit this note

A reason is required. The change is kept as history and the note is marked manually adjusted for EVV.