Background: Abdominal pain is a common symptom encountered by emergency medical services (EMS) in Sweden. EMS nurses follow a structured process involving clinical history, physical examination, and final assessment, as guided by regional protocols. However, little is known about EMS nurses' adherence to these guidelines. Objective: This study aims to evaluate adherence to regional guidelines for managing abdominal pain in EMS and explore whether EMS nurses' educational level is associated with adherence. Methods: A retrospective, descriptive review of EMS case records for patients with ESS Code 6 (abdominal pain) was conducted. Data were analyzed to compare adherence to guidelines between EMS nurses with and without specialized education. Results: A total of 600 cases were reviewed. Guideline adherence was suboptimal in several areas, such as pain intensity documented in only 36 % of cases, and abdominal palpation performed in 70 %. EMS nurses with specialized education were more likely to administer pain relief, perform abdominal palpation, and measure blood glucose. Conclusion: Adherence to guidelines for managing abdominal pain in EMS was limited, particularly in documenting pain intensity. The findings suggest that a higher level of education among EMS nurses may improve compliance with assessment and treatment protocols.