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Notes/Taylor Frey/Aug 4, 2026, 9:00 AM
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Note · Taylor Frey

completedEVV pendingclient signed·Aug 4, 2026, 9:00 AM · 300 min
Service record
Taylor Frey · Day support services
PDF
Aug 4, 20269:00 AM – 2:00 PM · 300 min · 20 unitsSam Nguyencompletedacceptedclient signed
Clock in
Aug 4, 2026, 9:00 AM
44.9823, -93.2624
Clock out
Aug 4, 2026, 2:00 PM
44.9804, -93.2551
Level of interaction
Skills worked on
Daily activitiesPick each activity you did with Taylor
  • Accompanied Taylor on community outings, providing support as needed to promote comfort and participation
  • Assisted Taylor with hygiene routines to promote consistency
  • Supported Taylor in practicing coping strategies during moments of stress or frustration
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 4, 2026, 2:02 PM
  • Clientsigned with code Aug 4, 2026, 2:01 PM
  • Reviewaccepted on submission
Authorization SA-2026-00132PMI 45678901UMPI A100000003POS 99
Accepted Aug 4, 2026, 2:02 PM

Aggregator record

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

Provider tax ID
41-0000000
PMI #
45678901
Service code
T2021 UC
Units
20 × 15 min
Place of service
99 · Other / community
Rendering staff
Sam Nguyen · UMPI A100000003
Authorization
SA-2026-00132
Clock in
Aug 4, 2026, 9:00 AM
Clock out
Aug 4, 2026, 2:00 PM
GPS at clock in
44.98231, -93.26238 · ±8 m
GPS at clock out
44.98038, -93.25515 · ±10 m
Manual entry
No
Client signature
Signed with code Aug 4, 2026, 2:01 PM

Tasks

2 of 2 completed

  • Personal care / ADLs
  • Skill building per support plan

Shift note

Day support services at the center. Taylor joined the morning group walk, then the art activity (painting). Lunch with peers. Participated in the afternoon music group and led one song request.

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Kept with the note and exported as EVV evidence

No edits since creation.

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