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Notes/Jordan Abelard/Jul 4, 2026, 10:00 AM
JA

Note · Jordan Abelard

completedEVV pendingclient signed·Jul 4, 2026, 10:00 AM · 240 min
Service record
Jordan Abelard · Respite care, in home
PDF
Jul 4, 202610:00 AM – 2:00 PM · 240 min · 16 unitsSam Nguyencompletedreturnedclient signed
Clock in
Jul 4, 2026, 10:00 AM
44.9819, -93.2554
Clock out
Jul 4, 2026, 2:00 PM
44.9794, -93.2634
Medications on 2026-07-04
  • 09:15Omeprazole20 mg
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 Jul 4, 2026, 2:02 PM
  • Clientsigned with code Jul 4, 2026, 2:01 PM
  • Reviewreturned Jul 4, 2026, 4:00 PM by Mustafa Ali: Add what prompting you gave during the community outing.
Authorization SA-2026-00102PMI 12345678UMPI A100000003POS 12
Returned for correction Jul 4, 2026, 4:00 PM: Add what prompting you gave during the community outing.

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
Jul 4, 2026, 10:00 AM
Clock out
Jul 4, 2026, 2:00 PM
GPS at clock in
44.98185, -93.25542 · ±8 m
GPS at clock out
44.97939, -93.26336 · ±10 m
Manual entry
No
Client signature
Signed with code Jul 4, 2026, 2:01 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.

Edit history

Kept with the note and exported as EVV evidence

No edits since creation.

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