INTRODUCTION: COVID-19 coagulopathy is described most frequently as a hypercoagualable state, often leading to empiric anti-coagulant therapy However, COVID-19 can present with either thrombotic and/or hemorrhagic complications secondary to a platelet function diathesis or factor dysfunction We hypothesized that thromboelastography with platelet mapping (TEG-PM) would more accurately characterize an individual's COVID-19 coagulopathic state and that TEG-guided medical therapy would reduce complications and improve outcomes METHODS: Prospective, longitudinal chart reviews of 65 COVID-19 patients with TEG-PM data were performed at an 800-bed tertiary care hospital Clinician-initiated TEG-PM was drawn on admission and q48-72 hrs whenever possible Patients were divided into 2 groups depending on whether their coagulopathy ultimately resolved: 1) resolved/non-coagulopathic state (NC-TEG) or 2) persistent coagulopathic condition, either hyper- or hypo-coagulable (C-TEG) Outcomes included thrombotic/hemorrhagic complications, pulmonary failure, acute kidney injury (AKI) and non-survival Standard therapy was provided independently by attending clinicians, including the option of using pre-existing TEG-guided treatment algorithms RESULTS: D-dimer, CRP and ferritin, while significantly elevated in the sickest patients, could not differentiate coagulopathic from non-coagulopathic patients Platelet hyperactivity (MA-AA/ADP >50min), with or without thrombocytosis, was associated with thrombotic/ischemic complications Hemorrhagic complications (cerebrovascular, hemoptysis) were observed with elevated R (>8min) and decreased factor activity C-TEG patients had nearly a 40-fold increased risk for mechanical ventilation (p=0 0002), 2 7 for AKI (p=0 0027), 33 7 dialysis (p=0 0152) and 13 3-fold increased risk of death (p