Introduction: Optimal discharge communication between healthcare providers and parents who present to the emergency department (ED) with their children is not well understood. Current research regarding discharge communication is equivocal and predominantly focused on evaluating different delivery formats or strategies with little attention given to communication behaviours or the context in which the communication occurs. The objective of this study was to characterize the process and structure of discharge communication in a pediatric ED context. Methods: Real-time video observation and follow-up surveys were used in two academic pediatric EDs in Canada. Parents who presented with their child to the ED with one of six illness presentations, a Canadian Triage Acuity Score of 3-5 were eligible to participate. All ED physicians, learners, and staff members were also eligible. Provider-parent communication was analyzed using the Roter Interaction Analysis System (RIAS) to code each utterance. Parent health literacy and anxiety were measured upon admission to the ED. Parent recall of important discharge information and satisfaction with communication was assessed within 72 hours of discharge. Results: A total of 107 ED patient visits were video recorded and a total of 70,000 utterances were coded across six illness presentations: abdominal pain (n=23), asthma (n=7), bronchiolitis (n=4), diarrhea/vomiting (n=20), fever (n=27), and minor head injury (n=26). The average length of stay for participants was 3 hours, with an average of three provider interactions per visit. Interactions ranged in time from less than one minute up to 29 minutes, with an average of six minutes per interaction. The majority of visits were first episodes for the presenting illness (63.2%). Physician utterances coded most commonly involved giving medical information (22.9%), whereas nurses most commonly gave orientation instructions (20.9%). Learners were most likely to employ active listening techniques (14.2%). Communication that provided post-discharge instructions for parents comprised 8.5% of all utterances. Overall, providers infrequently assessed parental understanding of information (2.0%). Only 26% of parents recalled receiving important discharge information deemed relevant to their childs disposition. Yet, parent satisfaction with the amount of information communicated during the ED visit was generally high (89.6% agreed or strongly agreed). Conclusion: This is the first study of ED discharge communication to be conducted in a pediatric setting using video observation methods. Provider-parent communication was predominantly characterized by giving medical information, with little time devoted to preparing families to care for their child at home. Greater assessment of parent comprehension of discharge communication is needed to ensure that parents understand important instructions and know when to seek further care.