Reference no: EM133274636

A 14-year-old male is brought to the Emergency Department via ambulance with a report of the patient being found unresponsive. The report given by the paramedics is that the patient's mother, who had not seen the child for over 24 hours, came home to find her son lying on the sofa unresponsive. Copious quantities of black-colored vomit were evident. The paramedics report the child is a diabetic and gives himself his own medication. His mother told the medics she was unsure when her son last took his medication. The patient himself offers no history whatsoever. The paramedics express deep concern regarding the social situation in which they found this child. The mother has not yet arrived at the Department to provide further information.

The medical record doesn't say he was diagnosed with a diabetic coma, but it looks like he had a diabetic coma. Do I need to include coma in the code or exclude coma because the doctor's note doesn't say he has a coma?