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Notes/Riley Bergstrom/Aug 27, 2026, 3:00 PM
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Note · Riley Bergstrom

completedEVV pendingclient signed·Aug 27, 2026, 3:00 PM · 240 min
Service record
Riley Bergstrom · Respite care, in home
PDF
Aug 27, 20263:00 PM – 7:00 PM · 240 min · 16 unitsSam Nguyencompletedacceptedclient signed
Clock in
Aug 27, 2026, 3:00 PM
44.9844, -93.2564
Clock out
Aug 27, 2026, 7:00 PM
44.9809, -93.2551
Level of interaction
Skills worked on
Daily activitiesPick each activity you did with Riley
  • Assisted Riley with physical activity or exercise as tolerated
  • Provided supervision and safety monitoring throughout the service
Support plan goals
Bedtime routine
Did Riley complete the bedtime routine with two or fewer prompts?
Progress review
signed by staff
Signatures
  • Caregiversigned Aug 27, 2026, 7:02 PM
  • Clientsigned with code Aug 27, 2026, 7:01 PM
  • Reviewaccepted on submission
Authorization SA-2026-00117PMI 23456789UMPI A100000003POS 12
Accepted Aug 27, 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 27, 2026, 3:00 PM
Clock out
Aug 27, 2026, 7:00 PM
GPS at clock in
44.98437, -93.25636 · ±8 m
GPS at clock out
44.98091, -93.25515 · ±10 m
Manual entry
No
Client signature
Signed with code Aug 27, 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

No edits since creation.

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