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Note that the reference implementations are generally limited to code for representing the resource contents in their native form and parsing & serializing them as XML and JSON. Some of the implementations provide support for building, using and reasoning with resource definitions. A few implementations include a client that conforms to the RESTful API.

Full blown open source implementations for FHIR, some of which use these reference implementations, are listed on the HL7 wiki.

It is not necessary to use these particular implementations in order to be conformant. Any other approach may be used, including code generated from the schemas.