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Notes/Casey Dahl/Jun 16, 2026, 3:30 PM
CD

Note · Casey Dahl

completedEVV pendingclient signed·Jun 16, 2026, 3:30 PM · 90 min
Service record
Casey Dahl · Homemaker, home management
PDF
Jun 16, 20263:30 PM – 5:00 PM · 90 min · 6 unitsTobi Okaforcompletedacceptedclient signed
Clock in
Jun 16, 2026, 3:30 PM
44.9819, -93.2644
Clock out
Jun 16, 2026, 5:00 PM
44.9818, -93.2557
Medications on 2026-06-16
  • 20:00Lamotrigine100 mg
  • 08:00Metformin500 mg
  • 20:00Metformin500 mg
Level of interaction
Skills worked on
Daily activitiesPick each activity you did with Casey
  • Assisted Casey with hygiene routines to promote consistency
  • Assisted Casey with household tasks such as laundry, dishes, and tidying living areas
  • Supported Casey with medication reminders and monitoring for side effects
Support plan goals
Take medications on schedule
Did Casey take scheduled medications with a reminder only?
Progress review
signed by staff
Signatures
  • Caregiversigned Jun 16, 2026, 5:02 PM
  • Clientsigned with code Jun 16, 2026, 5:01 PM
  • Reviewaccepted on submission
Authorization SA-2026-00089PMI 34567890UMPI A100000004POS 12
Accepted Jun 16, 2026, 5:02 PM

Aggregator record

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

Provider tax ID
41-0000000
PMI #
34567890
Service code
S5130 TF
Units
6 × 15 min
Place of service
12 · Home
Rendering staff
Tobi Okafor · UMPI A100000004
Authorization
SA-2026-00089
Clock in
Jun 16, 2026, 3:30 PM
Clock out
Jun 16, 2026, 5:00 PM
GPS at clock in
44.98193, -93.26436 · ±8 m
GPS at clock out
44.98176, -93.25566 · ±10 m
Manual entry
No
Client signature
Signed with code Jun 16, 2026, 5:01 PM

Tasks

2 of 2 completed

  • Personal care / ADLs
  • Skill building per support plan

Shift note

Homemaker, home management. Sorted mail, paid the electric bill online with Casey watching, and planned the week's meals. Made a shopping list for Thursday.

Edit history

Kept with the note and exported as EVV evidence

No edits since creation.

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